Provider Demographics
NPI:1649605965
Name:GREEN, KEVIN M (PHD, MS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-359-4840
Mailing Address - Fax:
Practice Address - Street 1:199 N 290 W
Practice Address - Street 2:SUITE 150
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1810
Practice Address - Country:US
Practice Address - Phone:801-406-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50020653902106H00000X
106H00000X
IDLMFT-6350106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist