Provider Demographics
NPI:1194048447
Name:ELLEN J SHABSHAI FOX, LISW
Entity type:Organization
Organization Name:ELLEN J SHABSHAI FOX, LISW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:J SHABSHAI
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:5056994312
Authorized Official - Phone:505-699-4312
Mailing Address - Street 1:2400 CALLE AMELIA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6280
Mailing Address - Country:US
Mailing Address - Phone:505-699-4312
Mailing Address - Fax:
Practice Address - Street 1:2400 CALLE AMELIA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6280
Practice Address - Country:US
Practice Address - Phone:505-699-4312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI062401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000598Medicaid