Provider Demographics
NPI:1659114965
Name:GREENWAY, MIKAYLA M (LAC)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:M
Last Name:GREENWAY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BRICK BLVD
Mailing Address - Street 2:SUITE 117 BLDG 4
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-7984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 BRICK BLVD
Practice Address - Street 2:SUITE 117 BLDG 4
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7984
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00795200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health