Provider Demographics
NPI:1467504308
Name:GREAVES, WILLIAM H (SW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:GREAVES
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WOODLAND AVE NW
Mailing Address - Street 2:STRONGHURST COMPLEX
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1498
Mailing Address - Country:US
Mailing Address - Phone:505-342-7205
Mailing Address - Fax:
Practice Address - Street 1:120 WOODLAND AVE NW
Practice Address - Street 2:STRONGHURST COMPLEX
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1498
Practice Address - Country:US
Practice Address - Phone:505-342-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 04719104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG 9041Medicaid