Provider Demographics
NPI:1063200863
Name:GREEN, KATELYN ELIZABETH
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21002 RICHEY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-6611
Mailing Address - Country:US
Mailing Address - Phone:618-946-1456
Mailing Address - Fax:
Practice Address - Street 1:1101 N STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052
Practice Address - Country:US
Practice Address - Phone:618-498-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health