Healthcare Provider Details

I. General information

NPI: 1144514811
Provider Name (Legal Business Name): KELLY ROBINSON GREEN MC, LPC, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2011
Last Update Date: 08/26/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W TALAVI BLVD STE 180
GLENDALE AZ
85306-1888
US

IV. Provider business mailing address

4747 N 7TH ST STE 100
PHOENIX AZ
85014-3654
US

V. Phone/Fax

Practice location:
  • Phone: 623-687-2865
  • Fax: 623-486-2739
Mailing address:
  • Phone: 602-279-7655
  • Fax: 602-680-1260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-1345
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-11799
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: