Provider Demographics
NPI:1114567310
Name:GREENE, ERIC M (PH D)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:GREENE
Suffix:
Gender:
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 W OLIVE AVE STE 570
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4549
Mailing Address - Country:US
Mailing Address - Phone:310-571-8904
Mailing Address - Fax:
Practice Address - Street 1:2600 W OLIVE AVE STE 570
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4549
Practice Address - Country:US
Practice Address - Phone:310-571-8904
Practice Address - Fax:323-639-5169
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2025-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31555103TP0814X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis