Provider Demographics
NPI:1093913451
Name:NELSON, KYLIE
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:
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 1:919 E MAHONEY AVE
Mailing Address - Street 2:LOT 14
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1147
Mailing Address - Country:US
Mailing Address - Phone:928-542-6700
Mailing Address - Fax:
Practice Address - Street 1:2929 N POWER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1745
Practice Address - Country:US
Practice Address - Phone:928-542-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-10288106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist