Provider Demographics
NPI:1891377586
Name:GREEN, KIMBERLEY YVETTE
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:YVETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2526
Mailing Address - Country:US
Mailing Address - Phone:216-322-7841
Mailing Address - Fax:
Practice Address - Street 1:3303 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2526
Practice Address - Country:US
Practice Address - Phone:216-322-7841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3245000000X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility