Provider Demographics
NPI:1982680534
Name:GREENE, RICHARD M (PSYD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:GREENE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 US HIGHWAY 1
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1612
Mailing Address - Country:US
Mailing Address - Phone:772-589-7680
Mailing Address - Fax:772-589-9294
Practice Address - Street 1:1515 US HIGHWAY 1
Practice Address - Street 2:SUITE 201
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1612
Practice Address - Country:US
Practice Address - Phone:772-589-7680
Practice Address - Fax:772-589-9294
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6929103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74155OtherBLUE CROSS BLUE SHIELD
FL74155OtherBLUE CROSS BLUE SHIELD