Provider Demographics
NPI:1386236628
Name:GREEN, ERYSSE AALIYAH
Entity type:Individual
Prefix:
First Name:ERYSSE
Middle Name:AALIYAH
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 1:2417 CROCKER WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8552
Mailing Address - Country:US
Mailing Address - Phone:925-238-6962
Mailing Address - Fax:
Practice Address - Street 1:1330 ARNOLD DR STE 148
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-6538
Practice Address - Country:US
Practice Address - Phone:925-310-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician