Provider Demographics
NPI:1912143512
Name:GREEN, KELLIE ELIZABETH (MA, CCC-SLP, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:ELIZABETH
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3173 WINDING WOODS DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8180
Mailing Address - Country:US
Mailing Address - Phone:614-342-0610
Mailing Address - Fax:
Practice Address - Street 1:3600 OLENTANGY RIVER RD
Practice Address - Street 2:BLDG D, STE 107
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3437
Practice Address - Country:US
Practice Address - Phone:614-974-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9217235Z00000X
OHL-310957174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist