Healthcare Provider Details

I. General information

NPI: 1700525540
Provider Name (Legal Business Name): CECILIA GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 09/25/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E 34TH AVE
PINE BLUFF AR
71601-7301
US

IV. Provider business mailing address

582 AR 365
MAYFLOWER AR
72106
US

V. Phone/Fax

Practice location:
  • Phone: 501-470-3500
  • Fax:
Mailing address:
  • Phone: 501-470-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number202928
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: