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General NPI Number Information
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NPI Number | 1770241309
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Entity Type | Individual
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Provider Name | KELLY J GREEN LSW
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Gender | Female
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 02/23/2024
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Provider Practice Location Address
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Address Line | 4115 BRIDGE AVE
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City | CLEVELAND
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State | OH
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Zip | 44113-3304
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Country | US
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Telephone | 216-631-5800
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Fax | 216-631-4595
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Provider Business Mailing Address
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Address Line | 4819 ALBERTLY AVE
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City | PARMA
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State | OH
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Zip | 44134-3323
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Country | US
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Telephone | 440-822-5305
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CDCA.184959
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 0002478
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.2309975
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License Number State | OH
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