Provider Demographics
NPI:1568006138
Name:GREEN, KIMBERLY KEISLING (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KEISLING
Last Name:GREEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5819 WINDING LN STE 105
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4067
Mailing Address - Country:US
Mailing Address - Phone:423-486-1266
Mailing Address - Fax:
Practice Address - Street 1:5819 WINDING LN STE 105
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4067
Practice Address - Country:US
Practice Address - Phone:423-877-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist