Provider Demographics
NPI:1275720187
Name:GREEN, SHELLI LEE (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:SHELLI
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-3306
Mailing Address - Country:US
Mailing Address - Phone:507-537-6297
Mailing Address - Fax:507-537-6578
Practice Address - Street 1:1501 STATE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-3306
Practice Address - Country:US
Practice Address - Phone:507-537-6297
Practice Address - Fax:507-537-6578
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer