MEDICARE: GREENPATH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1356971170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENPATH CLINIC

Provider Business Mailing Address
First Line	:	2132 DEEP WATER LN STE 240
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8565
Country	:	US
Telephone Number	:	630-272-5149
Fax Number	:

Provider Business Practice Location Address
First Line	:	2132 DEEP WATER LN STE 240
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8565
Country	:	US
Telephone Number	:	630-272-5149
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	GREG PERSUN
Credential	:
Telephone Number	:	630-272-5149

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/22/2020

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Directions to “GREENPATH CLINIC ” Practice Location

Language	Start Address	Practice Location

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