Provider Demographics
NPI:1871990317
Name:GREEN, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 PLAYERS CROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5534
Mailing Address - Country:US
Mailing Address - Phone:270-303-2640
Mailing Address - Fax:
Practice Address - Street 1:656 PLAYERS CROSSING WAY
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5534
Practice Address - Country:US
Practice Address - Phone:270-303-2640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-27
Last Update Date:2014-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3137235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist