Provider Demographics
NPI:1225329220
Name:GREENE, SHELLY (LAC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4060
Mailing Address - Country:US
Mailing Address - Phone:719-291-4006
Mailing Address - Fax:
Practice Address - Street 1:5265 N ACADEMY BLVD
Practice Address - Street 2:SUITE 1400
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4060
Practice Address - Country:US
Practice Address - Phone:719-291-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO853171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist