Provider Demographics
NPI:1023252368
Name:GREEN, SHANNON PATRICIA (LMHC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:PATRICIA
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 CENTRE LAKE DR NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1113
Mailing Address - Country:US
Mailing Address - Phone:321-768-6420
Mailing Address - Fax:321-768-6324
Practice Address - Street 1:490 CENTRE LAKE DR NE
Practice Address - Street 2:SUITE 150
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1113
Practice Address - Country:US
Practice Address - Phone:321-768-6420
Practice Address - Fax:321-768-6324
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8211101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767205522Medicaid