Basic Information
| Provider Information | |||||||||
| NPI: | 1720503337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ZYRIL | ||||||||
| MiddleName: | ROXAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41019 MARQUISE ST | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925321531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517081766 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3125 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584840 | ||||||||
| FaxNumber: | 9513584848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2017 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 117552 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.