Healthcare Provider Details

I. General information

NPI: 1396309076
Provider Name (Legal Business Name): JOHN NATHANIEL GREENE JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 N 42ND ST
MILWAUKEE WI
53209-3560
US

IV. Provider business mailing address

9484 N FAIRWAY DR
BAYSIDE WI
53217-1321
US

V. Phone/Fax

Practice location:
  • Phone: 414-449-1546
  • Fax:
Mailing address:
  • Phone: 414-232-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number3678-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3678-57
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3678-57
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number3678-57
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number3678-57
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number3678-57
License Number StateWI
# 7
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3678-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: