Provider Demographics
NPI:1629564364
Name:GREENE, NIKKI J
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:J
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 1:650 S COUNTRY CLUB DR APT 258
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2377
Mailing Address - Country:US
Mailing Address - Phone:480-912-0083
Mailing Address - Fax:
Practice Address - Street 1:1166 S GILBERT RD STE 106
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3461
Practice Address - Country:US
Practice Address - Phone:602-535-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician