Provider Demographics
NPI:1003950536
Name:KELLY K GREENE PC
Entity Type:Organization
Organization Name:KELLY K GREENE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:231-929-9040
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-6024
Mailing Address - Country:US
Mailing Address - Phone:231-775-6076
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:921 W 11TH ST STE 1W
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3002
Practice Address - Country:US
Practice Address - Phone:231-929-9040
Practice Address - Fax:231-929-5586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty