Provider Demographics
NPI:1215004304
Name:NELSON, KATIE DANIEL
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:DANIEL
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 1:465 N BELAIR RD STE 2D
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3190
Mailing Address - Country:US
Mailing Address - Phone:706-651-1260
Mailing Address - Fax:706-651-1383
Practice Address - Street 1:465 N BELAIR RD STE 2D
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3190
Practice Address - Country:US
Practice Address - Phone:706-651-1260
Practice Address - Fax:706-651-1383
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107424AMedicaid
GA000606317BMedicaid