Provider Demographics
NPI:1467554253
Name:GREENLAW, GARY (LICSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GREENLAW
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MARGIN ST
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-3847
Mailing Address - Country:US
Mailing Address - Phone:207-941-4289
Mailing Address - Fax:207-941-4062
Practice Address - Street 1:656 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5609
Practice Address - Country:US
Practice Address - Phone:207-941-4036
Practice Address - Fax:207-941-4062
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC15481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1525Medicare ID - Type Unspecified
Q51084Medicare UPIN