Provider Demographics
NPI:1538918818
Name:GREENWOOD, SAMUEL (CRM)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GREENWOOD
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7802 SW 45TH AVE APT 44
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1568
Mailing Address - Country:US
Mailing Address - Phone:503-747-9668
Mailing Address - Fax:
Practice Address - Street 1:14935 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9624
Practice Address - Country:US
Practice Address - Phone:503-660-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care