Provider Demographics
NPI:1215407192
Name:NELSON, KRISTINE K (LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 GRAND RIVER ANX STE 600
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-5312
Mailing Address - Country:US
Mailing Address - Phone:810-220-8192
Mailing Address - Fax:810-220-0402
Practice Address - Street 1:2060 GRAND RIVER ANX STE 600
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5312
Practice Address - Country:US
Practice Address - Phone:810-220-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801086616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health