Basic Information
| Provider Information | |||||||||
| NPI: | 1952766909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | AMBAR | ||||||||
| MiddleName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 W METROPOLITAN DR STE 403 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144805100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4000 W METROPOLITAN DR STE 403 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144805100 | ||||||||
| FaxNumber: | 7149392078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2015 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 103450 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.