Provider Demographics
NPI:1609996164
Name:GREENBERG, CONNIE J (MA, LP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17940 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3475
Mailing Address - Country:US
Mailing Address - Phone:763-476-8244
Mailing Address - Fax:763-475-6730
Practice Address - Street 1:801 TWELVE OAKS CENTER DR
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4601
Practice Address - Country:US
Practice Address - Phone:763-476-8244
Practice Address - Fax:763-475-6730
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3214103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist