Provider Demographics
NPI:1164783155
Name:GREEN, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 SHELDON DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-4122
Mailing Address - Country:US
Mailing Address - Phone:845-513-5754
Mailing Address - Fax:914-292-3422
Practice Address - Street 1:41 SHELDON DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-4122
Practice Address - Country:US
Practice Address - Phone:845-513-5754
Practice Address - Fax:914-292-3422
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY007808101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator