Basic Information
| Provider Information | |||||||||
| NPI: | 1114127214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MHAIII | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9343 TECH CENTER DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958262563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163886400 | ||||||||
| FaxNumber: | 9163886434 | ||||||||
| Practice Location | |||||||||
| Address1: | 9343 TECH CENTER DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958262563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163886400 | ||||||||
| FaxNumber: | 9163886434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.