Provider Demographics
NPI:1912778549
Name:GREENE, ELYSSA (LAC)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WILLOW DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-2837
Mailing Address - Country:US
Mailing Address - Phone:732-547-8821
Mailing Address - Fax:
Practice Address - Street 1:16 WILLOW DR APT 3B
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-2837
Practice Address - Country:US
Practice Address - Phone:732-547-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00363000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional