Provider Demographics
NPI:1578054292
Name:GREENE, LISETTE
Entity Type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:
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 1:36 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1120
Mailing Address - Country:US
Mailing Address - Phone:850-420-2498
Mailing Address - Fax:
Practice Address - Street 1:51 3RD ST BLDG 11
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1700
Practice Address - Country:US
Practice Address - Phone:850-420-2498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician