Provider Demographics
NPI:1154500791
Name:GREENLEE, ANDREW EDMOND I (MA, MED, LPC)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:EDMOND
Last Name:GREENLEE
Suffix:I
Gender:M
Credentials:MA, MED, LPC
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:GREENLEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:91 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3274
Mailing Address - Country:US
Mailing Address - Phone:313-263-0077
Mailing Address - Fax:313-883-0422
Practice Address - Street 1:150 STIMSON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2410
Practice Address - Country:US
Practice Address - Phone:313-993-4700
Practice Address - Fax:313-831-2299
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004038101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740313238OtherPROVIDER ID
MI36022440Medicaid