Provider Demographics
NPI:1114464781
Name:NELSON FAMILY COUNSELING, LLC.
Entity Type:Organization
Organization Name:NELSON FAMILY COUNSELING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSCED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FAGAN-NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-826-3566
Mailing Address - Street 1:705 E LINCOLN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6406
Mailing Address - Country:US
Mailing Address - Phone:309-826-3566
Mailing Address - Fax:309-452-9814
Practice Address - Street 1:705 E LINCOLN ST STE 302
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6406
Practice Address - Country:US
Practice Address - Phone:309-826-3566
Practice Address - Fax:309-452-9814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490093161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty