Provider Demographics
NPI:1982011680
Name:GREENFIELD, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:GREENFIELD
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 1:130 CORRIDOR RD UNIT 3292
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-7833
Mailing Address - Country:US
Mailing Address - Phone:904-638-6388
Mailing Address - Fax:
Practice Address - Street 1:130 CORRIDOR RD UNIT 3292
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32004-7833
Practice Address - Country:US
Practice Address - Phone:904-638-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT--19-75783106S00000X
NY644665121174400000X
NY554788111174400000X
NY550416111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist