MEDICARE: KATHLEEN GREEN LCSW

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	101YM0800X	Mental Health Counselor	149.026894	IL

General Provider Information

NPI Number	:	1538919204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN GREEN LCSW

Provider Business Mailing Address
First Line	:	2501 CHATHAM RD STE N
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1345 W FARGO AVE APT 1W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1839
Country	:	US
Telephone Number	:	312-761-9513
Fax Number	:

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

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	03/25/2024

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