Healthcare Provider Details

I. General information

NPI: 1184616765
Provider Name (Legal Business Name): MARIE GREENSPAN PHD, MSCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7316 REDBLOOM RD NW
ALBUQUERQUE NM
87114-6407
US

IV. Provider business mailing address

PO BOX 65669
ALBUQUERQUE NM
87193-5669
US

V. Phone/Fax

Practice location:
  • Phone: 505-365-1935
  • Fax: 505-792-6837
Mailing address:
  • Phone: 505-365-1935
  • Fax: 505-792-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1142
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301003263
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: