Provider Demographics
NPI:1790201671
Name:GREENOUGH, AMY RAE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RAE
Last Name:GREENOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9438 ABINGDON CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3313
Mailing Address - Country:US
Mailing Address - Phone:607-280-4240
Mailing Address - Fax:
Practice Address - Street 1:9438 ABINGDON CT
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3313
Practice Address - Country:US
Practice Address - Phone:607-280-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health