Basic Information
| Provider Information | |||||||||
| NPI: | 1104226406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470 | ||||||||
| Address2: | |||||||||
| City: | CIMARRON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678350470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858210037 | ||||||||
| FaxNumber: | 6202250279 | ||||||||
| Practice Location | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 6202250276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 08/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9358 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.