Provider Demographics
NPI:1689111841
Name:A SHARED PATH LLC
Entity Type:Organization
Organization Name:A SHARED PATH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRU
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBEZNICK BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-730-6735
Mailing Address - Street 1:4608 SAM BRATTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5333
Mailing Address - Country:US
Mailing Address - Phone:505-730-6735
Mailing Address - Fax:
Practice Address - Street 1:4011 BARBARA LOOP SE
Practice Address - Street 2:SUITE 107
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1039
Practice Address - Country:US
Practice Address - Phone:505-730-6735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-077301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty