Provider Demographics
NPI:1972115640
Name:NELSON, KALEB
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 N MAPLEWOOD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 602
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4551
Practice Address - Country:US
Practice Address - Phone:773-340-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0217631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical