Provider Demographics
NPI:1104512938
Name:GREENE, AUSTIN RAY
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:RAY
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 EASTERN AVE APT I
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-9774
Mailing Address - Country:US
Mailing Address - Phone:937-876-9596
Mailing Address - Fax:
Practice Address - Street 1:313 CHILLICOTHE AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7378
Practice Address - Country:US
Practice Address - Phone:937-393-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAOD-101YA0400XMedicaid
OHBH-101YM0800XMedicaid