Basic Information
| Provider Information | |||||||||
| NPI: | 1528326527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | GERRY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GREENE | ||||||||
| OtherFirstName: | STEPHEN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4642 MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974021417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413376041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974043212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417432611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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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 | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.