Healthcare Provider Details

I. General information

NPI: 1376948059
Provider Name (Legal Business Name): KATHLEEN GREEN M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2789 ORTIZ AVE
FORT MYERS FL
33905-7806
US

IV. Provider business mailing address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 239-275-3222
  • Fax: 239-275-7050
Mailing address:
  • Phone: 239-791-1586
  • Fax: 239-332-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: