Provider Demographics
NPI:1629787130
Name:GREEN, SHANTELL ALYSSIA
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:ALYSSIA
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 1:65 WILDERS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-9586
Mailing Address - Country:US
Mailing Address - Phone:919-453-3900
Mailing Address - Fax:
Practice Address - Street 1:65 WILDERS LN
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-9586
Practice Address - Country:US
Practice Address - Phone:919-453-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21-196645106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician