Provider Demographics
NPI:1124310131
Name:GREEN, SHAMEKA
Entity type:Individual
Prefix:MRS
First Name:SHAMEKA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAMEKA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, MFTI
Mailing Address - Street 1:2995 E SUNSET RD
Mailing Address - Street 2:D-117
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2726
Mailing Address - Country:US
Mailing Address - Phone:702-609-0547
Mailing Address - Fax:
Practice Address - Street 1:1901 SOUTH JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:702-815-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVM10639106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner