Provider Demographics
NPI:1356971170
Name:GREENPATH CLINIC
Entity type:Organization
Organization Name:GREENPATH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-272-5149
Mailing Address - Street 1:2132 DEEP WATER LN STE 240
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8565
Mailing Address - Country:US
Mailing Address - Phone:630-272-5149
Mailing Address - Fax:
Practice Address - Street 1:2132 DEEP WATER LN STE 240
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8565
Practice Address - Country:US
Practice Address - Phone:630-272-5149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty