Provider Demographics
NPI:1306914569
Name:NELKE, CONNIE FAYE (PHD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:FAYE
Last Name:NELKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BOLSOVER ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-2590
Mailing Address - Country:US
Mailing Address - Phone:713-986-3300
Mailing Address - Fax:713-986-3553
Practice Address - Street 1:2500 BOLSOVER ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-2590
Practice Address - Country:US
Practice Address - Phone:713-986-3300
Practice Address - Fax:713-986-3553
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040686003Medicaid
TX040686002Medicaid
TX8D4525Medicare ID - Type Unspecified