Provider Demographics
NPI:1356497325
Name:NELSON, KIMBERLY SIMONNE (LCMHC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SIMONNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LANE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 KIMEL PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6185
Practice Address - Country:US
Practice Address - Phone:336-718-7280
Practice Address - Fax:336-718-7290
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4349101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102130Medicaid
NC137PUOtherMENTAL HEALTH