Basic Information
| Provider Information | |||||||||
| NPI: | 1477179224 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GREEN | ||||||||
| FirstName: | KENDALL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7129 E BROADWAY RD UNIT 66 | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852081979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2804683805 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25615 N RANCH GATE RD | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852552141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805027726 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2020 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | TSLP12468 | AZ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | TSLP12468 | 01 | AZ | ARIZONA SPECIAL LICENSING SPEECH & HEARING PROFESSIONALS | OTHER |