Provider Demographics
NPI:1740893361
Name:GREENE, OTIS III (SUBSTANCE USE DISORD)
Entity type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:GREENE
Suffix:III
Gender:
Credentials:SUBSTANCE USE DISORD
Other - Prefix:
Other - First Name:KAMAU
Other - Middle Name:AKILI
Other - Last Name:SHABAZZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUBSTANCE USE DISORD
Mailing Address - Street 1:39407 VISTA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3283
Mailing Address - Country:US
Mailing Address - Phone:877-502-3218
Mailing Address - Fax:
Practice Address - Street 1:39407 VISTA DEL SOL
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3283
Practice Address - Country:US
Practice Address - Phone:877-502-3218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker