Provider Demographics
NPI:1518102151
Name:GREENIDGE, ANTHONY EUGENE (AZ LISAC - 15204)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:EUGENE
Last Name:GREENIDGE
Suffix:
Gender:M
Credentials:AZ LISAC - 15204
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17446 W PAPAGO ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1903
Mailing Address - Country:US
Mailing Address - Phone:919-827-6628
Mailing Address - Fax:
Practice Address - Street 1:17446 W PAPAGO ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1903
Practice Address - Country:US
Practice Address - Phone:919-827-6628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZ15204101YA0400X
NC1322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor