Provider Demographics
NPI:1437613858
Name:YELLOWMAN, GREG EVAN (LCSW)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:EVAN
Last Name:YELLOWMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E 20TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2151
Mailing Address - Country:US
Mailing Address - Phone:505-327-0293
Mailing Address - Fax:
Practice Address - Street 1:501 AIRPORT DR STE 260
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2401
Practice Address - Country:US
Practice Address - Phone:505-327-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-105961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical