Provider Demographics
NPI:1558579581
Name:GREENBAUM, SHELLEY ROBIN (LISW,LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:ROBIN
Last Name:GREENBAUM
Suffix:
Gender:F
Credentials:LISW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FARRIS ST TRLR 37
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5946
Mailing Address - Country:US
Mailing Address - Phone:505-885-4001
Mailing Address - Fax:505-887-6437
Practice Address - Street 1:111 FARRIS ST TRLR 37
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5946
Practice Address - Country:US
Practice Address - Phone:505-885-4001
Practice Address - Fax:505-887-6437
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-34421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000S6371Medicaid