Basic Information
| Provider Information | |||||||||
| NPI: | 1649724055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E MOJAVE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874016830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059478818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6100 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874023034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053267878 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | X-09690 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | X-11439 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 85-0431989 | 05 | NM | MEDICAID |