Healthcare Provider Details

I. General information

NPI: 1962716332
Provider Name (Legal Business Name): MICHAEL GREENE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
LITTLE NECK NY
11362-1150
US

IV. Provider business mailing address

8134 190TH ST
JAMAICA NY
11423-1041
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 718-468-1809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05430800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number073545-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: