Provider Demographics
NPI:1699852376
Name:GREENIDGE, GLORIA (LCSW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:GREENIDGE
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 1:3 HOMESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 BUSINESS PARK DR
Practice Address - Street 2:SUITE 203A
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2988
Practice Address - Country:US
Practice Address - Phone:203-506-5372
Practice Address - Fax:203-483-6400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003498101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003498OtherSTATE LICENSE