Provider Demographics
NPI:1144514811
Name:GREEN, KELLY ROBINSON (MC, LPC, LISAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ROBINSON
Last Name:GREEN
Suffix:
Gender:F
Credentials:MC, LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 N 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3654
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-680-1260
Practice Address - Street 1:5701 W TALAVI BLVD STE 180
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1888
Practice Address - Country:US
Practice Address - Phone:623-687-2865
Practice Address - Fax:623-486-2739
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1345101YA0400X
AZLPC-11799101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)