Basic Information
| Provider Information | |||||||||
| NPI: | 1154710176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENWELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233345 | ||||||||
| FaxNumber: | 6023233399 | ||||||||
| Practice Location | |||||||||
| Address1: | 3522 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027767676 | ||||||||
| FaxNumber: | 6027763002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-15199 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCSW-15199 | 01 | AZ | LICENSE # | OTHER |