MEDICARE: KIMBERLY C. R. GREENE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1710492657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY C. R. GREENE

Provider Business Mailing Address
First Line	:	1410 S CATALINA CIRCLE
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068
Country	:	US
Telephone Number	:	954-214-7210
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 S SANTA CATALINA CIR
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-6313
Country	:	US
Telephone Number	:	954-446-4099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	08/27/2020

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