Healthcare Provider Details

I. General information

NPI: 1326656851
Provider Name (Legal Business Name): SHANTIKA GREEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

IV. Provider business mailing address

10802 SE 144TH LOOP
HAPPY VALLEY OR
97086-8322
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8835
  • Fax:
Mailing address:
  • Phone: 503-358-6756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8611
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: