Provider Demographics
NPI:1073179966
Name:GRENZEBACK, SARAH (LPCC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:GRENZEBACK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:ABIQUIU
Mailing Address - State:NM
Mailing Address - Zip Code:87510-0817
Mailing Address - Country:US
Mailing Address - Phone:617-834-8204
Mailing Address - Fax:
Practice Address - Street 1:24 POLVADERA PL
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NM
Practice Address - Zip Code:87064-0199
Practice Address - Country:US
Practice Address - Phone:617-834-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0200251101YM0800X
NMCCMH0223711101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health