Provider Demographics
NPI:1033340203
Name:NELSON, KATHLEEN JEAN (MS ED)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JEAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008359101YM0800X, 101YP2500X
IL178.007110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health