Healthcare Provider Details

I. General information

NPI: 1346593605
Provider Name (Legal Business Name): ELLEN GREANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 NE COUCH ST
PORTLAND OR
97232-3067
US

IV. Provider business mailing address

1027 E BURNSIDE ST
PORTLAND OR
97214-1328
US

V. Phone/Fax

Practice location:
  • Phone: 503-239-8400
  • Fax: 503-239-8406
Mailing address:
  • Phone: 503-239-8400
  • Fax: 503-239-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15-01-05
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: