Provider Demographics
NPI:1245281716
Name:GREEN, KENNETH VINCENT (DCSW LCSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:VINCENT
Last Name:GREEN
Suffix:
Gender:M
Credentials:DCSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SPRINGHILL CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3546
Mailing Address - Country:US
Mailing Address - Phone:185-052-2855
Mailing Address - Fax:185-052-2856
Practice Address - Street 1:102 SPRINGHILL CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3546
Practice Address - Country:US
Practice Address - Phone:185-052-2855
Practice Address - Fax:185-052-2856
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL 36611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6191Medicare ID - Type UnspecifiedMENTAL HEALTH COUNSELING