Healthcare Provider Details

I. General information

NPI: 1184085839
Provider Name (Legal Business Name): JONATHAN J GREENAWALT LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 W PARK DR
LORAIN OH
44053
US

IV. Provider business mailing address

2115 W PARK DR
LORAIN OH
44053-1138
US

V. Phone/Fax

Practice location:
  • Phone: 440-989-4987
  • Fax: 440-282-4779
Mailing address:
  • Phone: 440-989-4987
  • Fax: 440-282-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA140854
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: