Provider Demographics
NPI:1679307284
Name:GREENE, CLINTON RANDALL (PHD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:RANDALL
Last Name:GREENE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CENTENNIAL PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0582
Mailing Address - Country:US
Mailing Address - Phone:850-431-1155
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTENNIAL PL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0582
Practice Address - Country:US
Practice Address - Phone:850-431-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12350103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist