Provider Demographics
NPI:1083338404
Name:GREENE, KELLY ELIZABETH (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:GREENE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07704-3040
Mailing Address - Country:US
Mailing Address - Phone:732-759-7358
Mailing Address - Fax:
Practice Address - Street 1:22 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1532
Practice Address - Country:US
Practice Address - Phone:732-639-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06785000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker