Provider Demographics
NPI:1134281835
Name:GREEN, CAROL R
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 SEARS AVE
Mailing Address - Street 2:SUITE 274
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5059
Mailing Address - Country:US
Mailing Address - Phone:502-893-1913
Mailing Address - Fax:502-893-7195
Practice Address - Street 1:173 SEARS AVE
Practice Address - Street 2:SUITE 274
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5059
Practice Address - Country:US
Practice Address - Phone:502-893-1913
Practice Address - Fax:502-893-7195
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0016101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0016OtherFEE BASED COUNSELOR