Provider Demographics
NPI:1407159791
Name:GREENWAY CLINIC OF PSYCHOLOGICAL SERVICES INC
Entity Type:Organization
Organization Name:GREENWAY CLINIC OF PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SOOKYUNG
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-851-3200
Mailing Address - Street 1:PO BOX 55458
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-0458
Mailing Address - Country:US
Mailing Address - Phone:323-851-3200
Mailing Address - Fax:323-851-3215
Practice Address - Street 1:3322 BARHAM BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1404
Practice Address - Country:US
Practice Address - Phone:323-851-3200
Practice Address - Fax:323-851-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty