Provider Demographics
NPI:1275059222
Name:GREENE, VICTORIA (IMF)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 803
Mailing Address - Street 2:
Mailing Address - City:MT BALDY
Mailing Address - State:CA
Mailing Address - Zip Code:91759-0803
Mailing Address - Country:US
Mailing Address - Phone:909-816-9911
Mailing Address - Fax:
Practice Address - Street 1:24028 LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325
Practice Address - Country:US
Practice Address - Phone:909-338-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF82130OtherBBS