Healthcare Provider Details

I. General information

NPI: 1205398005
Provider Name (Legal Business Name): SHAWNA MARIE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7565 AMADOR VALLEY BLVD 109
DUBLIN CA
94568
US

IV. Provider business mailing address

1795 CARPENTIER ST APT A
SAN LEANDRO CA
94577-4422
US

V. Phone/Fax

Practice location:
  • Phone: 866-206-2008
  • Fax:
Mailing address:
  • Phone: 866-206-2008
  • Fax: 866-317-1665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: