Provider Demographics
NPI:1770241309
Name:GREEN, KELLY J (LSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 ALBERTLY AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-3323
Mailing Address - Country:US
Mailing Address - Phone:440-822-5305
Mailing Address - Fax:
Practice Address - Street 1:4115 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3304
Practice Address - Country:US
Practice Address - Phone:216-631-5800
Practice Address - Fax:216-631-4595
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.184959101YA0400X
OH0002478175T00000X
OHS.2309975104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist