Basic Information
| Provider Information | |||||||||
| NPI: | 1154818409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENBERG | ||||||||
| FirstName: | RALLE | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685699 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
| FaxNumber: | 5086960401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2018 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 107792 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.