Healthcare Provider Details

I. General information

NPI: 1467277426
Provider Name (Legal Business Name): SHONN GREENGRASS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 INDIAN SCHOOL RD NE STE 200
ALBUQUERQUE NM
87110-4082
US

IV. Provider business mailing address

5001 INDIAN SCHOOL RD NE STE 200
ALBUQUERQUE NM
87110-4082
US

V. Phone/Fax

Practice location:
  • Phone: 505-548-9023
  • Fax: 505-531-8020
Mailing address:
  • Phone: 505-548-9023
  • Fax: 505-531-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB20260503
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: