Provider Demographics
NPI:1083627392
Name:GREEN, KIM KATHLEEN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:KATHLEEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 EAST 'H' STREET
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:906-779-3148
Practice Address - Street 1:787 MARKET STREET
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930
Practice Address - Country:US
Practice Address - Phone:906-482-7762
Practice Address - Fax:906-482-7893
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020793251041C0700X
MI68010862691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical