Provider Demographics
NPI:1275514077
Name:GREEN, KIMBERLY D (MED, LMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED, LMFT
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:D
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, LMFT
Mailing Address - Street 1:667 SPRING DRIVE EXT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9788
Mailing Address - Country:US
Mailing Address - Phone:253-225-5418
Mailing Address - Fax:877-410-5513
Practice Address - Street 1:667 SPRING DRIVE EXT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9788
Practice Address - Country:US
Practice Address - Phone:253-225-5418
Practice Address - Fax:877-410-5513
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00002194106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1091299Medicaid