Provider Demographics
NPI:1679006084
Name:GREENBAUM, SARA (LADC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GREENBAUM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1175
Mailing Address - Country:US
Mailing Address - Phone:651-251-5229
Mailing Address - Fax:651-251-5279
Practice Address - Street 1:555 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1175
Practice Address - Country:US
Practice Address - Phone:651-251-5229
Practice Address - Fax:651-251-5279
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303890101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)