Provider Demographics
NPI:1649759697
Name:NELSON, KAITLYN ROSE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
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 1:2785 S BAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6591
Mailing Address - Country:US
Mailing Address - Phone:844-668-6222
Mailing Address - Fax:888-975-0599
Practice Address - Street 1:2785 S BAY ST STE A
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6591
Practice Address - Country:US
Practice Address - Phone:844-668-6222
Practice Address - Fax:888-975-0599
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW20420101YM0800X, 1041C0700X
FL1-23-68353103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical