Provider Demographics
NPI:1902595150
Name:GREEN, KELLY ELIZABETH (LPCMH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 RIDON DR
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-1004
Mailing Address - Country:US
Mailing Address - Phone:302-690-4553
Mailing Address - Fax:
Practice Address - Street 1:13 RIDON DR
Practice Address - Street 2:
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-1004
Practice Address - Country:US
Practice Address - Phone:302-690-4553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0011367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health