Provider Demographics
NPI:1568734556
Name:KESHA GREEN LLC
Entity Type:Organization
Organization Name:KESHA GREEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KESHA
Authorized Official - Middle Name:PANIKA
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:706-332-0526
Mailing Address - Street 1:122 GREYSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 GREYSTONE CIR
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3141
Practice Address - Country:US
Practice Address - Phone:706-332-0526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health