Provider Demographics
NPI:1811561814
Name:GREENE, TIMOTHY BRUCE
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRUCE
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1102
Mailing Address - Country:US
Mailing Address - Phone:213-213-0100
Mailing Address - Fax:
Practice Address - Street 1:8836 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4832
Practice Address - Country:US
Practice Address - Phone:323-751-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator