Provider Demographics
NPI:1487873717
Name:GREEN, PAMELA (PHD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
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:PO BOX 5377
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32793-5377
Mailing Address - Country:US
Mailing Address - Phone:407-365-2599
Mailing Address - Fax:407-365-3132
Practice Address - Street 1:11325 LAKE UNDERHILL RD STE 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-5090
Practice Address - Country:US
Practice Address - Phone:407-365-2599
Practice Address - Fax:407-365-3132
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002246103G00000X, 103TA0700X, 103TF0200X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009418900Medicaid
FL209749400Medicaid