Basic Information
| Provider Information | |||||||||
| NPI: | 1467589275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1920 BLOSSOM CT | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945338009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073305488 | ||||||||
| FaxNumber: | 7073990268 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 ESTUDILLO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945774611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103529200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 36428 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.