Healthcare Provider Details

I. General information

NPI: 1821153560
Provider Name (Legal Business Name): DARRELL CORY GREENE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 BROADWAY STE 916
NEW YORK NY
10010-2007
US

IV. Provider business mailing address

444 BEARDS HOLLOW RD
RICHMONDVILLE NY
12149-3407
US

V. Phone/Fax

Practice location:
  • Phone: 212-929-5978
  • Fax: 646-478-9404
Mailing address:
  • Phone: 917-421-0954
  • Fax: 646-478-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number012091-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number012091-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number012091-01
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number012091-1
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number012091-1
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number012091-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: