Provider Demographics
NPI:1598347676
Name:GREENWALD, REBECCA CLARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:CLARK
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:CLARK
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:60 BELLA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2007
Mailing Address - Country:US
Mailing Address - Phone:415-446-8266
Mailing Address - Fax:
Practice Address - Street 1:60 BELLA VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2007
Practice Address - Country:US
Practice Address - Phone:415-446-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty