MEDICARE: DR. KIMBERLEY A GREEN PH.D., HSPP

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	20040602	IN
2	103TH0100X	Health Service Psychologist	20040602	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	084081	OTHER	SIHO - SOUTHEASTERN INDIANA HEALTH ORGANIZATION
2	000000533237	OTHER	ANTHEM BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	7453298	OTHER	AETNA
5	06010200	OTHER	MAGELLAN HEALTH SERVICES

General Provider Information

NPI Number	:	1821084476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLEY A GREEN PH.D., HSPP

Provider Business Mailing Address
First Line	:	1 UNIVERSITY BLVD
Second Line	:	COMMUNITY PSYCHOLOGICAL SERVICE
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-4400
Country	:	US
Telephone Number	:	314-516-5824
Fax Number	:	314-516-5347

Provider Business Practice Location Address
First Line	:	1 UNIVERSITY BLVD
Second Line	:	COMMUNITY PSYCHOLOGICAL SERVICE, 232 STADLER HALL
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-4400
Country	:	US
Telephone Number	:	314-516-5824
Fax Number	:	314-516-5347

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	11/26/2012

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Directions to “ DR. KIMBERLEY A GREEN PH.D., HSPP” Practice Location

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