Provider Demographics
NPI:1801803572
Name:GREEN, KELLY ELAINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ELAINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1801 GALAXY DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-3929
Mailing Address - Country:US
Mailing Address - Phone:254-699-9023
Mailing Address - Fax:254-690-9013
Practice Address - Street 1:1604 S W S YOUNG DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5003
Practice Address - Country:US
Practice Address - Phone:254-699-9023
Practice Address - Fax:254-690-9013
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S74XMedicare ID - Type Unspecified
TXS27828Medicare UPIN