Provider Demographics
NPI:1164601787
Name:GREEN, KIMBERLY M (CSC-AD, RAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:CSC-AD, RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 QUEENSBURY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1074
Mailing Address - Country:US
Mailing Address - Phone:301-864-0919
Mailing Address - Fax:
Practice Address - Street 1:4404 QUEENSBURY RD STE 105
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1074
Practice Address - Country:US
Practice Address - Phone:301-864-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCADD14102101YA0400X
MD210310714251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)