1821084476 NPI number — DR. KIMBERLEY A GREEN PH.D., HSPP

Table of content: DR. KIMBERLEY A GREEN PH.D., HSPP (NPI 1821084476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821084476 NPI number — DR. KIMBERLEY A GREEN PH.D., HSPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
KIMBERLEY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., HSPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821084476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 UNIVERSITY BLVD
Provider Second Line Business Mailing Address:
COMMUNITY PSYCHOLOGICAL SERVICE
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63121-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-516-5824
Provider Business Mailing Address Fax Number:
314-516-5347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
COMMUNITY PSYCHOLOGICAL SERVICE, 232 STADLER HALL
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63121-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-516-5824
Provider Business Practice Location Address Fax Number:
314-516-5347
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  20040602 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: 20040602 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 084081 . This is a "SIHO - SOUTHEASTERN INDIANA HEALTH ORGANIZATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000533237 . This is a "ANTHEM BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100167180A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7453298 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06010200 . This is a "MAGELLAN HEALTH SERVICES" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com