MEDICARE: DR. KELLY GREEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1093295263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY GREEN PH.D.

Provider Business Mailing Address
First Line	:	712 S CLIFTON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-1978
Country	:	US
Telephone Number	:	832-434-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 MARKET ST STE 3037
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3313
Country	:	US
Telephone Number	:	215-746-7337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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Directions to “ DR. KELLY GREEN PH.D.” Practice Location

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