Provider Demographics
NPI:1821153560
Name:GREENE, DARRELL CORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:CORY
Last Name:GREENE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:444 BEARDS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:RICHMONDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12149-3407
Mailing Address - Country:US
Mailing Address - Phone:917-421-0954
Mailing Address - Fax:646-478-9404
Practice Address - Street 1:1123 BROADWAY STE 916
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-2007
Practice Address - Country:US
Practice Address - Phone:212-929-5978
Practice Address - Fax:646-478-9404
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012091-1103TA0400X, 103TC0700X, 103TF0000X, 103TP2701X, 103T00000X
NY012091-01103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV2H521Medicare PIN