Provider Demographics
NPI:1821512500
Name:GREENE, CAMERON (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 TRELLIS RIDGE LN APT 1
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4509
Mailing Address - Country:US
Mailing Address - Phone:920-860-6658
Mailing Address - Fax:
Practice Address - Street 1:2420 NICOLET DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7003
Practice Address - Country:US
Practice Address - Phone:920-465-2452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
OHAT0059922255A2300X
WI3031-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program