Healthcare Provider Details

I. General information

NPI: 1811514169
Provider Name (Legal Business Name): KIM GREEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W ALBEMARLE AVE
LANSDOWNE PA
19050-1126
US

IV. Provider business mailing address

4012 BRUNSWICK AVE
DREXEL HILL PA
19026-3406
US

V. Phone/Fax

Practice location:
  • Phone: 610-931-3650
  • Fax:
Mailing address:
  • Phone: 610-931-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY GREEN
Title or Position: LPC/ THERAPIST
Credential: LPC
Phone: 610-931-3650