Healthcare Provider Details

I. General information

NPI: 1376669804
Provider Name (Legal Business Name): KATHRYN T. GREEN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2127 S HERRON DR
NAMPA ID
83686-5342
US

IV. Provider business mailing address

2127 S HERRON DR
NAMPA ID
83686-5342
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-8347
  • Fax:
Mailing address:
  • Phone: 208-342-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-124
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number124
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: