Healthcare Provider Details

I. General information

NPI: 1902275365
Provider Name (Legal Business Name): BENJAMIN GREENBERG PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S SAINT FRANCIS DR STE B
SANTA FE NM
87505-4036
US

IV. Provider business mailing address

50 VERANO LOOP
SANTA FE NM
87508-8827
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-6853
  • Fax: 505-372-6979
Mailing address:
  • Phone: 505-629-6853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1721
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY004333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: