Provider Demographics
NPI:1114584372
Name:GREENWELL, CHARNA TAMAR (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHARNA
Middle Name:TAMAR
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2122
Mailing Address - Country:US
Mailing Address - Phone:765-494-3795
Mailing Address - Fax:
Practice Address - Street 1:715 CLINIC DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2122
Practice Address - Country:US
Practice Address - Phone:765-494-3795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003395A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist