Provider Demographics
NPI:1376522797
Name:GREEN, KRISTIN H (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:H
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 SEMINOLE DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5823
Mailing Address - Country:US
Mailing Address - Phone:386-214-1570
Mailing Address - Fax:
Practice Address - Street 1:330 KAY LARKIN DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-2307
Practice Address - Country:US
Practice Address - Phone:386-329-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL136901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical