Healthcare Provider Details

I. General information

NPI: 1558970004
Provider Name (Legal Business Name): ELICE GREENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 N TATUM BLVD STE 100
PHOENIX AZ
85028-6037
US

IV. Provider business mailing address

11201 N TATUM BLVD STE 100
PHOENIX AZ
85028-6037
US

V. Phone/Fax

Practice location:
  • Phone: 623-263-3966
  • Fax:
Mailing address:
  • Phone: 623-263-3966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-82293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: