=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700057460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY LEE GREENE LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 05/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 DESIARD ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71203-3913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-345-8200
-----------------------------------------------------
Fax | 318-342-8049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 WILSON RD
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-4468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-506-9575
-----------------------------------------------------
Fax | 770-506-9369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4126
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4343
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------