Provider Demographics
NPI:1861552283
Name:GREENE, MARJORIE ELLEN (LMSW)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ELLEN
Last Name:GREENE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 PARKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-1734
Mailing Address - Country:US
Mailing Address - Phone:734-663-8518
Mailing Address - Fax:
Practice Address - Street 1:400 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3304
Practice Address - Country:US
Practice Address - Phone:734-668-8667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010122541041C0700X
MI4101005554106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0891069Medicare ID - Type Unspecified