Provider Demographics
NPI:1295043586
Name:GREEN, KAT TUMBLIN (PHD)
Entity Type:Individual
Prefix:
First Name:KAT
Middle Name:TUMBLIN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 N 900 E
Mailing Address - Street 2:OFFICE 268
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3536
Mailing Address - Country:US
Mailing Address - Phone:801-422-6475
Mailing Address - Fax:
Practice Address - Street 1:1190 N 900 E
Practice Address - Street 2:OFFICE 268
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3536
Practice Address - Country:US
Practice Address - Phone:801-422-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9870487-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical