Provider Demographics
NPI:1972197168
Name:GREEN, KHALILAH
Entity Type:Individual
Prefix:
First Name:KHALILAH
Middle Name:
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 1:9222 S PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-1419
Mailing Address - Country:US
Mailing Address - Phone:773-454-8912
Mailing Address - Fax:
Practice Address - Street 1:9222 S PERRY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-1419
Practice Address - Country:US
Practice Address - Phone:773-454-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator