Healthcare Provider Details

I. General information

NPI: 1871831727
Provider Name (Legal Business Name): KESHA GREEN LMF, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10 SUITE 304I
BROOKLYN CENTER MN
55429-3072
US

IV. Provider business mailing address

3300 COUNTY ROAD 10 SUITE 304I
BROOKLYN CENTER MN
55429-3072
US

V. Phone/Fax

Practice location:
  • Phone: 763-355-5461
  • Fax: 763-355-5692
Mailing address:
  • Phone: 763-355-5461
  • Fax: 763-355-5692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW #25186
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: