Provider Demographics
NPI:1952084519
Name:GREEN, KIMBERLY HOPE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HOPE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARTIN CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5554
Mailing Address - Country:US
Mailing Address - Phone:618-977-0801
Mailing Address - Fax:
Practice Address - Street 1:8 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-1345
Practice Address - Country:US
Practice Address - Phone:618-688-4731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health