Provider Demographics
NPI:1821084476
Name:GREEN, KIMBERLEY A (PHD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:COMMUNITY PSYCHOLOGICAL SERVICE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5824
Mailing Address - Fax:314-516-5347
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:COMMUNITY PSYCHOLOGICAL SERVICE, 232 STADLER HALL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4400
Practice Address - Country:US
Practice Address - Phone:314-516-5824
Practice Address - Fax:314-516-5347
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040602103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
084081OtherSIHO - SOUTHEASTERN INDIANA HEALTH ORGANIZATION
000000533237OtherANTHEM BC/BS
IN100167180AMedicaid
7453298OtherAETNA
06010200OtherMAGELLAN HEALTH SERVICES
06010200OtherMAGELLAN HEALTH SERVICES