Provider Demographics
NPI:1124237615
Name:GREEN, JUDITH MASON (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:MASON
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 5TH AVE
Mailing Address - Street 2:10F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-4512
Mailing Address - Country:US
Mailing Address - Phone:212-244-1722
Mailing Address - Fax:
Practice Address - Street 1:286 5TH AVE
Practice Address - Street 2:10F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4512
Practice Address - Country:US
Practice Address - Phone:212-244-1722
Practice Address - Fax:212-686-5330
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006298103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV26411Medicare ID - Type Unspecified