Provider Demographics
NPI:1992968770
Name:GREEN, KERRY LYNN
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
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 1:400 SW 1ST AVE APT 2608
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3496
Mailing Address - Country:US
Mailing Address - Phone:908-642-3644
Mailing Address - Fax:
Practice Address - Street 1:400 SW 1ST AVE APT 906
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3487
Practice Address - Country:US
Practice Address - Phone:908-642-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL133331041C0700X
FLSW133331041C0700X
NY0855731041C0700X
NY0835041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical