Healthcare Provider Details

I. General information

NPI: 1912616673
Provider Name (Legal Business Name): RUFUS GREENE JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GOLD AVE SW
ALBUQUERQUE NM
87102-3283
US

IV. Provider business mailing address

7925 HENDRIX RD NE
ALBUQUERQUE NM
87110-1523
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-9124
  • Fax: 505-000-0000
Mailing address:
  • Phone: 505-400-5187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0894
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: