Provider Demographics
NPI:1265027460
Name:GREEN, SHAWNTIA RENEE
Entity Type:Individual
Prefix:
First Name:SHAWNTIA
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BITTING ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-2185
Mailing Address - Country:US
Mailing Address - Phone:910-970-6196
Mailing Address - Fax:
Practice Address - Street 1:1018 N BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3316
Practice Address - Country:US
Practice Address - Phone:910-295-2609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician