Provider Demographics
NPI:1609233329
Name:GREENE, GWENDOLYN TERESE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:TERESE
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:PO BOX 620251
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89162-0251
Mailing Address - Country:US
Mailing Address - Phone:702-930-5958
Mailing Address - Fax:702-796-9490
Practice Address - Street 1:1649 WEST HORIZON RIDGE PARKWAY
Practice Address - Street 2:SUITE 130
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5080
Practice Address - Country:US
Practice Address - Phone:702-930-5958
Practice Address - Fax:702-796-9490
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0633106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program