Provider Demographics
NPI:1972828895
Name:GREEN, KENNETH JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAMES
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 W 71ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-2344
Mailing Address - Country:US
Mailing Address - Phone:317-731-2505
Mailing Address - Fax:
Practice Address - Street 1:2505 W 71ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-2344
Practice Address - Country:US
Practice Address - Phone:317-731-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-03
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005965A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical