Provider Demographics
NPI:1811471766
Name:GREENLAW, TRISTAN OLIVER (LCPC)
Entity type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:OLIVER
Last Name:GREENLAW
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 COURT ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4725
Mailing Address - Country:US
Mailing Address - Phone:207-922-7572
Mailing Address - Fax:
Practice Address - Street 1:61 MAIN ST STE 62
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6469
Practice Address - Country:US
Practice Address - Phone:207-922-2158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5121101YM0800X
MECC6591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health