Provider Demographics
NPI:1386795482
Name:GREENE, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8529 PORTER HILL TER
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3910
Mailing Address - Country:US
Mailing Address - Phone:619-464-3664
Mailing Address - Fax:619-644-1302
Practice Address - Street 1:4700 SPRING ST
Practice Address - Street 2:306
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5263
Practice Address - Country:US
Practice Address - Phone:619-464-3664
Practice Address - Fax:619-644-1302
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37422101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37422OtherLMFT