Provider Demographics
NPI:1396309076
Name:GREENE, JOHN NATHANIEL JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NATHANIEL
Last Name:GREENE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9484 N FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1321
Mailing Address - Country:US
Mailing Address - Phone:414-232-0077
Mailing Address - Fax:
Practice Address - Street 1:6100 N 42ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-3560
Practice Address - Country:US
Practice Address - Phone:414-449-1546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-27
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3678-57103TA0400X, 103TB0200X, 103TC2200X, 103TF0200X, 103TM1800X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy