Provider Demographics
NPI:1689256802
Name:GREENLEAF, SHANIKA
Entity Type:Individual
Prefix:MRS
First Name:SHANIKA
Middle Name:
Last Name:GREENLEAF
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 1:13170 DUTCHTOWN POINT AVE APT 433
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-0102
Mailing Address - Country:US
Mailing Address - Phone:985-688-1712
Mailing Address - Fax:
Practice Address - Street 1:58155 CHINN ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3601
Practice Address - Country:US
Practice Address - Phone:225-385-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1017012508Medicaid