Provider Demographics
NPI:1811514169
Name:KIM GREEN
Entity type:Organization
Organization Name:KIM GREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:610-931-3650
Mailing Address - Street 1:4012 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3406
Mailing Address - Country:US
Mailing Address - Phone:610-931-3650
Mailing Address - Fax:
Practice Address - Street 1:217 W ALBEMARLE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1126
Practice Address - Country:US
Practice Address - Phone:610-931-3650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty