MEDICARE: KENDRELL GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1336852631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRELL GREEN

Provider Business Mailing Address
First Line	:	1215 ALPHA RD
Second Line	:
City	:	HENDERSON
State	:	NC
Zip	:	27536-2523
Country	:	US
Telephone Number	:	252-203-3945
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 ELM ST
Second Line	:
City	:	WELDON
State	:	NC
Zip	:	27890-1934
Country	:	US
Telephone Number	:	252-537-4005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	01/02/2023

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Directions to “ KENDRELL GREEN ” Practice Location

Language	Start Address	Practice Location

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