Provider Demographics
NPI:1518485705
Name:GREENE, MIRIAM L
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:L
Last Name:GREENE
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 1:111 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-757-0300
Mailing Address - Fax:309-757-0400
Practice Address - Street 1:111 19TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3754
Practice Address - Country:US
Practice Address - Phone:309-757-0300
Practice Address - Fax:309-757-0400
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL33465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty