Provider Demographics
NPI:1548429459
Name:GREENE, MARY 'MOLLY' MARTHA (MA)
Entity Type:Individual
Prefix:
First Name:MARY 'MOLLY'
Middle Name:MARTHA
Last Name:GREENE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 STAUNTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1540
Mailing Address - Country:US
Mailing Address - Phone:304-925-6473
Mailing Address - Fax:304-925-2205
Practice Address - Street 1:3718 STAUNTON AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1540
Practice Address - Country:US
Practice Address - Phone:304-925-6473
Practice Address - Fax:304-925-2205
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV834103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist