Provider Demographics
NPI:1588819429
Name:GREENE, JOHN ROBERT (LLP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:GREENE
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 E NEWELL ST
Mailing Address - Street 2:P.O. BOX 867
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8795
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:231-689-7345
Practice Address - Street 1:1049 E NEWELL ST
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8795
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:231-689-7345
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010999103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral