Provider Demographics
NPI:1568195279
Name:HART-GREEN, SHANTAVIA MARIE
Entity Type:Individual
Prefix:MRS
First Name:SHANTAVIA
Middle Name:MARIE
Last Name:HART-GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHANTAVIA
Other - Middle Name:M
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7090 SAMUEL MORSE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3442
Mailing Address - Country:US
Mailing Address - Phone:443-554-1078
Mailing Address - Fax:
Practice Address - Street 1:7090 SAMUEL MORSE DR STE 1
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3442
Practice Address - Country:US
Practice Address - Phone:443-554-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst