Provider Demographics
NPI:1679107213
Name:GREENE, ANTOIN JOHN
Entity type:Individual
Prefix:
First Name:ANTOIN
Middle Name:JOHN
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LINCOLN AVE APT 30
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-2007
Mailing Address - Country:US
Mailing Address - Phone:484-510-6951
Mailing Address - Fax:
Practice Address - Street 1:606 E BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1751
Practice Address - Country:US
Practice Address - Phone:844-924-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician