Provider Demographics
NPI:1366594509
Name:GREENHALGH, GORDON G (PHD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:G
Last Name:GREENHALGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7115
Mailing Address - Country:US
Mailing Address - Phone:386-427-2241
Mailing Address - Fax:386-427-2242
Practice Address - Street 1:211 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7115
Practice Address - Country:US
Practice Address - Phone:386-427-2241
Practice Address - Fax:386-427-2242
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist