Provider Demographics
NPI:1164457529
Name:GREENE, RALPH E JR (PHD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:E
Last Name:GREENE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-1411
Mailing Address - Country:US
Mailing Address - Phone:606-564-4016
Mailing Address - Fax:606-564-8288
Practice Address - Street 1:505 2ND ST
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-1008
Practice Address - Country:US
Practice Address - Phone:606-796-3021
Practice Address - Fax:606-796-9881
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30608012Medicaid
0509309Medicare ID - Type Unspecified
KY30608012Medicaid
P72507Medicare UPIN