Provider Demographics
NPI:1134966765
Name:GREEN, SHANICE CHARDE
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:CHARDE
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 1:310 26TH ST
Mailing Address - Street 2:
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509-2502
Mailing Address - Country:US
Mailing Address - Phone:919-519-6125
Mailing Address - Fax:
Practice Address - Street 1:310 26TH ST
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-2502
Practice Address - Country:US
Practice Address - Phone:919-519-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000031074167106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician