Healthcare Provider Details

I. General information

NPI: 1245574516
Provider Name (Legal Business Name): TRINA L. GREENWALD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N BRADNER AVE
MARION IN
46952-2449
US

IV. Provider business mailing address

515 N BRADNER AVE
MARION IN
46952-2449
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-8000
  • Fax: 877-731-2066
Mailing address:
  • Phone: 765-664-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71002182A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number28084011A
License Number StateIN

VIII. Authorized Official

Name: TRINA L GREENWALD
Title or Position: OWNER/PRACTITIONER
Credential: FNP-C, PMHNP-BC
Phone: 765-664-8000