Provider Demographics
NPI:1619420379
Name:GREENLEAF PSYCHOLOGY
Entity Type:Organization
Organization Name:GREENLEAF PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARBONEAU
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, QEEG, BCN, BCB
Authorized Official - Phone:509-838-8066
Mailing Address - Street 1:3157 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-5136
Mailing Address - Country:US
Mailing Address - Phone:509-838-8066
Mailing Address - Fax:800-594-8305
Practice Address - Street 1:3157 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-5136
Practice Address - Country:US
Practice Address - Phone:509-838-8066
Practice Address - Fax:800-594-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002046305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1790773463OtherINDIVIDUAL NPI