Provider Demographics
NPI:1740807965
Name:GREENE, WANDA (LPC/LMHC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:LPC/LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6120
Mailing Address - Country:US
Mailing Address - Phone:478-279-6256
Mailing Address - Fax:
Practice Address - Street 1:215 CARL VINSON PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5825
Practice Address - Country:US
Practice Address - Phone:478-353-6820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009088101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health