Provider Demographics
NPI:1871831727
Name:GREEN, KESHA (LMF, LICSW)
Entity Type:Individual
Prefix:MS
First Name:KESHA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMF, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 COUNTY ROAD 10
Mailing Address - Street 2:SUITE 304I
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3072
Mailing Address - Country:US
Mailing Address - Phone:763-355-5461
Mailing Address - Fax:763-355-5692
Practice Address - Street 1:3300 COUNTY ROAD 10
Practice Address - Street 2:SUITE 304I
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3072
Practice Address - Country:US
Practice Address - Phone:763-355-5461
Practice Address - Fax:763-355-5692
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
MNLICSW #251861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist