Provider Demographics
NPI:1225152275
Name:NELSON, KIOSHA (MSW)
Entity Type:Individual
Prefix:MS
First Name:KIOSHA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7484 PEPPERTREE LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0737
Mailing Address - Country:US
Mailing Address - Phone:760-500-7190
Mailing Address - Fax:
Practice Address - Street 1:1323 W COLTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4554
Practice Address - Country:US
Practice Address - Phone:909-792-0747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid