Basic Information
| Provider Information | |||||||||
| NPI: | 1639310261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENHAW | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | DELANE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CADCA II, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3810 ROSIN CT STE 170 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162838280 | ||||||||
| FaxNumber: | 9164054620 | ||||||||
| Practice Location | |||||||||
| Address1: | 3810 ROSIN CT STE 170 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1692838280 | ||||||||
| FaxNumber: | 9162838259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2009 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 12211 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.