Provider Demographics
NPI:1699027789
Name:GREENAWALT, HEATHER RAYEE (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RAYEE
Last Name:GREENAWALT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N UNION ST
Mailing Address - Street 2:STCHCN/UPC
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2736
Mailing Address - Country:US
Mailing Address - Phone:716-375-7500
Mailing Address - Fax:716-701-6854
Practice Address - Street 1:135 N UNION ST
Practice Address - Street 2:STCHCN/UPC
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2736
Practice Address - Country:US
Practice Address - Phone:716-375-7500
Practice Address - Fax:716-701-6854
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0793711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03532689Medicaid
NY03532689Medicaid