Provider Demographics
NPI:1255105912
Name:GREENE, KELSEY BROOKE (CNA #1263149)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:BROOKE
Last Name:GREENE
Suffix:
Gender:F
Credentials:CNA #1263149
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:BROOKE
Other - Last Name:REYNOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3161 ARMOURDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-4415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41769 ENTERPRISE CIR N
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5626
Practice Address - Country:US
Practice Address - Phone:951-531-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician