MEDICARE: KERRY LYNN GREEN

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	1041C0700X	Clinical Social Worker	13333	FL
2	1041C0700X	Clinical Social Worker	SW13333	FL
3	1041C0700X	Clinical Social Worker	085573	NY
4	1041C0700X	Clinical Social Worker	083504	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992968770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY LYNN GREEN

Provider Business Mailing Address
First Line	:	400 SW 1ST AVE APT 2608
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3496
Country	:	US
Telephone Number	:	908-642-3644
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 SW 1ST AVE APT 906
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3487
Country	:	US
Telephone Number	:	908-642-3644
Fax Number	:

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

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	05/03/2023

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Directions to “ KERRY LYNN GREEN ” Practice Location

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