Healthcare Provider Details

I. General information

NPI: 1407635774
Provider Name (Legal Business Name): SHANNON GREENE R. EEG T., CLTM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 JAY ELL DR
RICHARDSON TX
75081-2063
US

IV. Provider business mailing address

11206 UNIVERSITY AVE APT 204
LUBBOCK TX
79423-6194
US

V. Phone/Fax

Practice location:
  • Phone: 888-344-2947
  • Fax:
Mailing address:
  • Phone: 612-570-4675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: