Provider Demographics
NPI:1588751887
Name:GREEN, JUDITH LEMPERT (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:LEMPERT
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 1:2311 E STADIUM BLVD
Mailing Address - Street 2:#106
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4833
Mailing Address - Country:US
Mailing Address - Phone:734-665-2860
Mailing Address - Fax:
Practice Address - Street 1:2311 E STADIUM BLVD
Practice Address - Street 2:#105N, OFFICE 6
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4833
Practice Address - Country:US
Practice Address - Phone:734-665-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001670103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI001670OtherPSYCHOLOGIST LICENSE
11277419OtherCAQH PROVIDER #
MI620H14645OtherBCBSM PROVIDER