Provider Demographics
NPI:1023153830
Name:GREEN, SHEILA (MS)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W OLLA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-8216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 E SOUTHERN AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7669
Practice Address - Country:US
Practice Address - Phone:480-833-4330
Practice Address - Fax:480-833-1902
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA1725231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470667OtherAHCCCS PIN