Provider Demographics
NPI:1366650368
Name:GREEN, SHELLEY K (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 E SUNRISE BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1479
Mailing Address - Country:US
Mailing Address - Phone:954-296-7913
Mailing Address - Fax:
Practice Address - Street 1:1948 E SUNRISE BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1479
Practice Address - Country:US
Practice Address - Phone:954-296-7913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0001443106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist