Provider Demographics
NPI:1245574516
Name:TRINA L. GREENWALD LLC
Entity Type:Organization
Organization Name:TRINA L. GREENWALD LLC
Other - Org Name:SERENITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:765-664-8000
Mailing Address - Street 1:515 N BRADNER AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2449
Mailing Address - Country:US
Mailing Address - Phone:765-664-8000
Mailing Address - Fax:
Practice Address - Street 1:515 N BRADNER AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2449
Practice Address - Country:US
Practice Address - Phone:765-664-8000
Practice Address - Fax:877-731-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X
IN71002182A363LP0808X
IN28084011A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200844580Medicaid
ININ1279Medicare PIN
IN200844580Medicaid