Basic Information
| Provider Information | |||||||||
| NPI: | 1851530083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNERS-GREENE | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 GRAND CONCOURSE | ||||||||
| Address2: | STE 417 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185847204 | ||||||||
| FaxNumber: | 7185848394 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 GRAND CONCOURSE | ||||||||
| Address2: | STE 417 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185847204 | ||||||||
| FaxNumber: | 7185848394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2009 | ||||||||
| LastUpdateDate: | 02/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 7302 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 192488 | 05 | NY | MEDICAID |