Provider Demographics
NPI:1639735921
Name:GREENE, CHASITY DAWN
Entity Type:Individual
Prefix:
First Name:CHASITY
Middle Name:DAWN
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 1:648 MORREL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-8260
Mailing Address - Country:US
Mailing Address - Phone:863-242-4990
Mailing Address - Fax:
Practice Address - Street 1:648 MORREL AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-8260
Practice Address - Country:US
Practice Address - Phone:863-242-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician