Healthcare Provider Details

I. General information

NPI: 1003938085
Provider Name (Legal Business Name): STACY GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 HOUSTON OAKS DR
PARIS KY
40361-2704
US

IV. Provider business mailing address

142 LACKAWANNA RD
LEXINGTON KY
40503-1914
US

V. Phone/Fax

Practice location:
  • Phone: 606-584-1169
  • Fax: 606-763-6245
Mailing address:
  • Phone: 859-599-3019
  • Fax: 859-533-3019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3175
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: