MEDICARE: SHANNON PATRICIA GREEN LMHC

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	101YM0800X	Mental Health Counselor	MH 8211	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023252368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON PATRICIA GREEN LMHC

Provider Business Mailing Address
First Line	:	490 CENTRE LAKE DR NE
Second Line	:	SUITE 150
City	:	PALM BAY
State	:	FL
Zip	:	32907-1113
Country	:	US
Telephone Number	:	321-768-6420
Fax Number	:	321-768-6324

Provider Business Practice Location Address
First Line	:	490 CENTRE LAKE DR NE
Second Line	:	SUITE 150
City	:	PALM BAY
State	:	FL
Zip	:	32907-1113
Country	:	US
Telephone Number	:	321-768-6420
Fax Number	:	321-768-6324

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

Provider Enumeration Date	:	04/30/2009
Last Update Date	:	04/30/2009

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