Provider Demographics
NPI:1558883215
Name:GREEN, KIERSTYN B
Entity Type:Individual
Prefix:
First Name:KIERSTYN
Middle Name:B
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 1:9995 N COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4710
Mailing Address - Country:US
Mailing Address - Phone:217-821-2153
Mailing Address - Fax:
Practice Address - Street 1:2803 S BANKER ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2978
Practice Address - Country:US
Practice Address - Phone:217-540-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2020-10-01
Deactivation Date:2018-06-08
Deactivation Code:
Reactivation Date:2018-07-25
Provider Licenses
StateLicense IDTaxonomies
MO2017023547235Z00000X
IL146014216235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist