Provider Demographics
NPI:1932378809
Name:GREENBAUM, TINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:GREENBAUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 CHRISTIE AVE,
Mailing Address - Street 2:416
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608
Mailing Address - Country:US
Mailing Address - Phone:631-988-1109
Mailing Address - Fax:
Practice Address - Street 1:17 TASMAN LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1123
Practice Address - Country:US
Practice Address - Phone:631-988-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR063269-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN2Z451Medicare PIN