Provider Demographics
NPI:1205440872
Name:GREEN, KEEDRA ALESIA (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KEEDRA
Middle Name:ALESIA
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4401
Mailing Address - Country:US
Mailing Address - Phone:601-443-8169
Mailing Address - Fax:
Practice Address - Street 1:23 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4401
Practice Address - Country:US
Practice Address - Phone:601-443-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7195235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist