Provider Demographics
NPI:1912607532
Name:GREEN, BRIAN EUGENE (DAOM, LCSW, LAC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EUGENE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DAOM, LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 E 14TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4800
Mailing Address - Country:US
Mailing Address - Phone:415-652-8214
Mailing Address - Fax:
Practice Address - Street 1:1684 E 14TH ST STE 207
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4800
Practice Address - Country:US
Practice Address - Phone:415-652-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298911041C0700X
CA16841171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171100000XOther Service ProvidersAcupuncturist