Provider Demographics
NPI:1215518584
Name:NELSON, KIMBERLY NICOLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:NELSON
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 1:200 EVERGREEN AVE APT 5F
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2722
Mailing Address - Country:US
Mailing Address - Phone:914-830-1592
Mailing Address - Fax:
Practice Address - Street 1:200 EVERGREEN AVE APT 5F
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2722
Practice Address - Country:US
Practice Address - Phone:914-830-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289218748106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician