Healthcare Provider Details

I. General information

NPI: 1821084476
Provider Name (Legal Business Name): KIMBERLEY A GREEN PH.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY BLVD COMMUNITY PSYCHOLOGICAL SERVICE, 232 STADLER HALL
SAINT LOUIS MO
63121-4400
US

IV. Provider business mailing address

1 UNIVERSITY BLVD COMMUNITY PSYCHOLOGICAL SERVICE
SAINT LOUIS MO
63121-4400
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5824
  • Fax: 314-516-5347
Mailing address:
  • Phone: 314-516-5824
  • Fax: 314-516-5347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040602
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20040602
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: