Provider Demographics
NPI:1558802975
Name:GREEN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:2484 CANYADA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-5268
Mailing Address - Country:US
Mailing Address - Phone:626-658-7735
Mailing Address - Fax:
Practice Address - Street 1:15340 DEVONSHIRE ST STE 7
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2760
Practice Address - Country:US
Practice Address - Phone:323-538-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-18
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist