Provider Demographics
NPI:1598070351
Name:GREEN, KIMBERLY A (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 BROADWAY UNIT 210
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5763
Mailing Address - Country:US
Mailing Address - Phone:404-354-6152
Mailing Address - Fax:
Practice Address - Street 1:1601 BROADWAY UNIT 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5763
Practice Address - Country:US
Practice Address - Phone:404-354-6152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0140661041C0700X
GACSW0042721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical