Provider Demographics
NPI:1104128057
Name:GREEN, KRISTEN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:HOBGOOD
Mailing Address - State:NC
Mailing Address - Zip Code:27843-0248
Mailing Address - Country:US
Mailing Address - Phone:252-717-7924
Mailing Address - Fax:252-824-0660
Practice Address - Street 1:512 ARBUTUS DR E
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2272
Practice Address - Country:US
Practice Address - Phone:252-717-7924
Practice Address - Fax:252-824-0660
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9007235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist