Provider Demographics
NPI:1194245969
Name:GREEN, SHANNON LARAY
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LARAY
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 DALECREST DR UNIT 2109
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-1769
Mailing Address - Country:US
Mailing Address - Phone:702-448-9285
Mailing Address - Fax:
Practice Address - Street 1:3800 DALECREST DR UNIT 2109
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-1769
Practice Address - Country:US
Practice Address - Phone:702-448-9285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health