Provider Demographics
NPI:1972098390
Name:GREENAWALT, JODIE LEE
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:LEE
Last Name:GREENAWALT
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 1:805 LANCASTER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-4503
Mailing Address - Country:US
Mailing Address - Phone:978-320-1610
Mailing Address - Fax:
Practice Address - Street 1:43 CHUBB RD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-7804
Practice Address - Country:US
Practice Address - Phone:508-302-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician