Provider Demographics
NPI:1710167739
Name:GREEN, NICOLETTE (LSCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSCSW, LCAC
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7927 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-3724
Mailing Address - Country:US
Mailing Address - Phone:913-302-8450
Mailing Address - Fax:913-624-9799
Practice Address - Street 1:7927 FLOYD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-3724
Practice Address - Country:US
Practice Address - Phone:913-302-8450
Practice Address - Fax:913-624-9799
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS240101YA0400X
KS40811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1174513444Medicaid