Healthcare Provider Details

I. General information

NPI: 1336119346
Provider Name (Legal Business Name): GLEN DAVID GREENBERG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 CHRISTIANA RD STE 201A
NEWARK DE
19713-4221
US

IV. Provider business mailing address

PO BOX 594
WESTTOWN PA
19395-0594
US

V. Phone/Fax

Practice location:
  • Phone: 610-566-0501
  • Fax: 610-566-0502
Mailing address:
  • Phone: 610-566-0501
  • Fax: 610-566-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS 004797-L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberB1 0000441
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS 004797-L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberB1 0000441
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: