Provider Demographics
NPI:1598303596
Name:GREEN, KENYATTA (CSW)
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MARSHALL WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7378
Mailing Address - Country:US
Mailing Address - Phone:801-430-1280
Mailing Address - Fax:801-747-6860
Practice Address - Street 1:377 MARSHALL WAY STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7378
Practice Address - Country:US
Practice Address - Phone:801-430-1280
Practice Address - Fax:801-747-6860
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical