Basic Information
| Provider Information | |||||||||
| NPI: | 1114539764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KIANA | ||||||||
| MiddleName: | ROSELLA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 HEADLAND DR SW STE 600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303115437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4708325973 | ||||||||
| FaxNumber: | 8778875316 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 HEADLAND DR SW STE 600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303115437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4708325973 | ||||||||
| FaxNumber: | 8778875316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW007873 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | Q176105196 | 01 | GA | MEDICARE | OTHER |