=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336473073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JASON GREENBERG PSY.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2009
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 BARB ST STE A
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98315-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-815-0488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27615 WOODSIDE RD NE
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98346-9510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-815-0488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY30676
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------