Provider Demographics
NPI:1336119346
Name:GREENBERG, GLEN DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:DAVID
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 594
Mailing Address - Street 2:
Mailing Address - City:WESTTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19395-0594
Mailing Address - Country:US
Mailing Address - Phone:610-566-0501
Mailing Address - Fax:610-566-0502
Practice Address - Street 1:774 CHRISTIANA RD STE 201A
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4221
Practice Address - Country:US
Practice Address - Phone:610-566-0501
Practice Address - Fax:610-566-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 004797-L103G00000X, 103TC0700X
DEB1 0000441103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
214951OtherCOMPPSYCH
3350135OtherAETNA
PA001187272003Medicaid
221962OtherVALUE OPTIONS
0488565000OtherMAGELLAN
0427479000OtherAMERIHEALTH
DE1000033037Medicaid
70659OtherCIGNA BEHAVIORAL HEALTH
001661440OtherBS PERSONAL CHOICE
1000033037OtherDELAWARE PHYSICIANS CARE
1000033037OtherDELAWARE PHYSICIANS CARE
PA604971Medicare ID - Type Unspecified