Provider Demographics
NPI:1336852631
Name:GREEN, KENDRELL
Entity Type:Individual
Prefix:
First Name:KENDRELL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 ALPHA RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2523
Mailing Address - Country:US
Mailing Address - Phone:252-203-3945
Mailing Address - Fax:
Practice Address - Street 1:100 ELM ST
Practice Address - Street 2:
Practice Address - City:WELDON
Practice Address - State:NC
Practice Address - Zip Code:27890-1934
Practice Address - Country:US
Practice Address - Phone:252-537-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)