Healthcare Provider Details

I. General information

NPI: 1316720832
Provider Name (Legal Business Name): LYDIA GREENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE STE 402
CHICAGO IL
60657-5084
US

IV. Provider business mailing address

615 EUCLID CT
HIGHLAND PARK IL
60035-1271
US

V. Phone/Fax

Practice location:
  • Phone: 847-323-8189
  • Fax:
Mailing address:
  • Phone: 847-323-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: