Basic Information
| Provider Information | |||||||||
| NPI: | 1003334186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENFIELD | ||||||||
| FirstName: | LEIGH ANN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11600 ELDRIDGE AVENUE | ||||||||
| Address2: | PHOENIX HOUSE OUTPATIENT MENTAL HEALTH PROGRAM | ||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YM0800X | 100551 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100551 | 01 | CA | BOARD OF BEHAVIORAL SCIENCES - INTERN MARRIAGE AND FAMILY THERAPIST NUMBER | OTHER |