Provider Demographics
NPI:1679921837
Name:GREENLEE, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREENLEE
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 1:2506 GALEN DR STE 108
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7047
Mailing Address - Country:US
Mailing Address - Phone:217-262-9508
Mailing Address - Fax:217-703-8988
Practice Address - Street 1:2506 GALEN DR STE 108
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7047
Practice Address - Country:US
Practice Address - Phone:217-262-9508
Practice Address - Fax:217-703-8988
Is Sole Proprietor?:No
Enumeration Date:2016-05-28
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0133661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical