Provider Demographics
NPI:1104247600
Name:GREEN, CATHERINE
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1767 BEDFORD AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-3331
Mailing Address - Country:US
Mailing Address - Phone:646-204-1116
Mailing Address - Fax:
Practice Address - Street 1:2625 E 14TH ST STE 200
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3973
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:718-401-0108
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY688858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist