Healthcare Provider Details

I. General information

NPI: 1396336160
Provider Name (Legal Business Name): STEPHANIE GREENE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BULLSNAKE ROAD
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 838
EL PRADO NM
87529-0838
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-2205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: