Provider Demographics
NPI:1093098915
Name:GREEN, KELLI (BS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:1735 HORNE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH STREET, SUITE 5
Practice Address - Street 2:BUTTERFLY EFFECTS
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist