Provider Demographics
NPI:1548933401
Name:GREEN, KIELY SHAY (BA)
Entity type:Individual
Prefix:
First Name:KIELY
Middle Name:SHAY
Last Name:GREEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9612 LUCERNE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2926
Mailing Address - Country:US
Mailing Address - Phone:773-706-6802
Mailing Address - Fax:
Practice Address - Street 1:1545 SAWTELLE BLVD STE 31
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3272
Practice Address - Country:US
Practice Address - Phone:949-474-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
W236865778OtherAETNA