Provider Demographics
NPI:1407593130
Name:GREELIS, MADELINE MARIE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:MARIE
Last Name:GREELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15339 MARTIN ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2610
Mailing Address - Country:US
Mailing Address - Phone:763-550-7991
Mailing Address - Fax:
Practice Address - Street 1:15339 MARTIN ST NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-2610
Practice Address - Country:US
Practice Address - Phone:763-550-7991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNM293-115-481-914103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst