MEDICARE: GREENWICH EDUCATION GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-13-12876	CT

General Provider Information

NPI Number	:	1437541778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENWICH EDUCATION GROUP

Provider Business Mailing Address
First Line	:	78 HARVARD AVE
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-5548
Country	:	US
Telephone Number	:	203-661-1609
Fax Number	:

Provider Business Practice Location Address
First Line	:	78 HARVARD AVE
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-5548
Country	:	US
Telephone Number	:	203-661-1609
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIOR ANALYST
Name	:	SHANNON EVELYN MATTHEWS
Credential	:	BCBA
Telephone Number	:	203-661-1609

Provider Enumeration Date	:	02/24/2015
Last Update Date	:	02/24/2015

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