Healthcare Provider Details

I. General information

NPI: 1770241309
Provider Name (Legal Business Name): KELLY J GREEN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 BRIDGE AVE
CLEVELAND OH
44113-3304
US

IV. Provider business mailing address

4819 ALBERTLY AVE
PARMA OH
44134-3323
US

V. Phone/Fax

Practice location:
  • Phone: 216-631-5800
  • Fax: 216-631-4595
Mailing address:
  • Phone: 440-822-5305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184959
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002478
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2309975
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: