Provider Demographics
NPI:1982895868
Name:GREENE, SHANNON M (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:PHD, LMFT
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 93042
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78709-3042
Mailing Address - Country:US
Mailing Address - Phone:512-775-1908
Mailing Address - Fax:
Practice Address - Street 1:2306 LAKE AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-4546
Practice Address - Country:US
Practice Address - Phone:512-775-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLMFT4900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00364BOtherBCBS OF TX