MEDICARE: CHARLES A GREENMAN LP

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	103TC0700X	Clinical Psychologist	3049	MN

General Provider Information

NPI Number	:	1629015631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES A GREENMAN LP

Provider Business Mailing Address
First Line	:	11421 LIVE OAK DR
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55305-2589
Country	:	US
Telephone Number	:	612-593-0864
Fax Number	:

Provider Business Practice Location Address
First Line	:	5910 SHINGLE CREEK PKWY STE 150
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2324
Country	:	US
Telephone Number	:	763-569-5200
Fax Number	:	763-569-5201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	07/02/2020

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