Provider Demographics
NPI:1861611691
Name:GREEN, KIMBERLY DAWN (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MAIN ST
Mailing Address - Street 2:SUITE 515
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-5215
Mailing Address - Country:US
Mailing Address - Phone:903-875-8104
Mailing Address - Fax:903-872-7558
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:SUITE 515
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-5215
Practice Address - Country:US
Practice Address - Phone:903-875-8104
Practice Address - Fax:903-872-7558
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18293101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158803001Medicaid