Provider Demographics
NPI:1063188241
Name:NIELSEN, KIMBERLY SUE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:NIELSEN
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 1:380 SOLON RD APT 512
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1442
Mailing Address - Country:US
Mailing Address - Phone:214-675-9243
Mailing Address - Fax:
Practice Address - Street 1:1285 N MAIN ST STE 101-5
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1511
Practice Address - Country:US
Practice Address - Phone:682-651-7621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
TX86040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional