Healthcare Provider Details

I. General information

NPI: 1396573580
Provider Name (Legal Business Name): SHANTEL GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MERCANTILE PLAZA DR STE 300
FORT WORTH TX
76137-4206
US

IV. Provider business mailing address

1751 RIVER RUN STE 200
FORT WORTH TX
76107-6670
US

V. Phone/Fax

Practice location:
  • Phone: 817-482-0537
  • Fax:
Mailing address:
  • Phone: 817-500-0785
  • Fax: 817-241-1963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106566
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: