Provider Demographics
NPI:1194222034
Name:NELSON, CHRISTIE ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 4TH STREET TRAFFICWAY
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048
Mailing Address - Country:US
Mailing Address - Phone:913-682-2000
Mailing Address - Fax:
Practice Address - Street 1:4101 4TH STREET TRAFFICWAY
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2018-10-03
Deactivation Date:2018-05-31
Deactivation Code:
Reactivation Date:2018-10-03
Provider Licenses
StateLicense IDTaxonomies
KY129671103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist