Provider Demographics
NPI:1013662154
Name:GREENGOSS, CHARLES J
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:GREENGOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 JUDSON AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2452
Mailing Address - Country:US
Mailing Address - Phone:847-951-3872
Mailing Address - Fax:
Practice Address - Street 1:6820 MADRONE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9578
Practice Address - Country:US
Practice Address - Phone:480-313-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist