Provider Demographics
NPI:1871016634
Name:GREENE, AUDREY RAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:RAE
Last Name:GREENE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:AUDREY
Other - Middle Name:RAE
Other - Last Name:KOSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:12867 HUNTSMAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4476
Mailing Address - Country:US
Mailing Address - Phone:208-731-2619
Mailing Address - Fax:
Practice Address - Street 1:4805 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2198
Practice Address - Country:US
Practice Address - Phone:513-241-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist