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General NPI Number Information
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NPI Number | 1013662154
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Entity Type | Individual
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Provider Name | CHARLES J GREENGOSS
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Gender | Male
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Dates
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Enumeration Date | 02/17/2022
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Last Update Date | 02/17/2022
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Provider Practice Location Address
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Address Line | 6820 MADRONE DR
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City | ROCKFORD
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State | MI
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Zip | 49341-9578
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Country | US
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Telephone | 480-313-6777
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Fax |
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Provider Business Mailing Address
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Address Line | 800 JUDSON AVE APT 201
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City | EVANSTON
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State | IL
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Zip | 60202-2452
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Country | US
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Telephone | 847-951-3872
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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