Provider Demographics
NPI:1336169515
Name:GREENE, KENNETH RYAN (LCSWR)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RYAN
Last Name:GREENE
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 N MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BAINBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13733-1233
Mailing Address - Country:US
Mailing Address - Phone:607-244-4668
Mailing Address - Fax:
Practice Address - Street 1:28 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:BAINBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13733-1233
Practice Address - Country:US
Practice Address - Phone:607-244-4668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT131411041C0700X
NYR049290-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00049290Medicaid
NYN67951Medicare ID - Type Unspecified