Provider Demographics
NPI:1457051468
Name:GREEN, SHANEESHA DENISE
Entity Type:Individual
Prefix:MS
First Name:SHANEESHA
Middle Name:DENISE
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:PO BOX 672
Mailing Address - Street 2:
Mailing Address - City:WAELDER
Mailing Address - State:TX
Mailing Address - Zip Code:78959-0672
Mailing Address - Country:US
Mailing Address - Phone:737-277-7258
Mailing Address - Fax:
Practice Address - Street 1:10604 SUNDAY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78747-2775
Practice Address - Country:US
Practice Address - Phone:737-277-7258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling