Healthcare Provider Details

I. General information

NPI: 1417311549
Provider Name (Legal Business Name): KELLY MAUREEN GREENE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 BUSINESS PARK DR STE 1
UTICA NY
13502
US

IV. Provider business mailing address

158 PARIS RD
NEW HARTFORD NY
13413-2442
US

V. Phone/Fax

Practice location:
  • Phone: 315-732-3431
  • Fax:
Mailing address:
  • Phone: 315-725-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004892
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: