MEDICARE: SHAWNDA GREEN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA90312	FL

General Provider Information

NPI Number	:	1699255737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWNDA GREEN LMT

Provider Business Mailing Address
First Line	:	8414 GOLDOME DR
Second Line	:
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-3320
Country	:	US
Telephone Number	:	727-495-3650
Fax Number	:

Provider Business Practice Location Address
First Line	:	4636 GLISSADE DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-5319
Country	:	US
Telephone Number	:	727-495-3650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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Directions to “ SHAWNDA GREEN LMT” Practice Location

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