Provider Demographics
NPI:1447939111
Name:GREENE, ALICIA ANTOINETTE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANTOINETTE
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 1:956 GRAHAM CAMPBELL LN
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-1896
Mailing Address - Country:US
Mailing Address - Phone:404-723-0715
Mailing Address - Fax:
Practice Address - Street 1:956 GRAHAM CAMPBELL LN
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-1896
Practice Address - Country:US
Practice Address - Phone:404-723-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health