Provider Demographics
NPI:1073157665
Name:GREENE, PRESTON (LMSW, CAADC)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 AMERICAS WAY APT 12518
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-7600
Mailing Address - Country:US
Mailing Address - Phone:231-881-2538
Mailing Address - Fax:
Practice Address - Street 1:8484 M 119 UNIT 17B
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9542
Practice Address - Country:US
Practice Address - Phone:231-535-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801014042104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker