Provider Demographics
NPI:1790221075
Name:GREENWALD, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GREENWALD
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 1:24411 WIMBLEDON RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3222
Mailing Address - Country:US
Mailing Address - Phone:216-464-0164
Mailing Address - Fax:
Practice Address - Street 1:6575 ASHTON LN
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139
Practice Address - Country:US
Practice Address - Phone:440-668-8564
Practice Address - Fax:877-844-4869
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2030068Medicaid