Provider Demographics
NPI:1417223371
Name:NELSON, KELLY M (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 QUAIL AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1134
Mailing Address - Country:US
Mailing Address - Phone:763-222-6383
Mailing Address - Fax:952-544-6405
Practice Address - Street 1:11708 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2014
Practice Address - Country:US
Practice Address - Phone:952-544-0964
Practice Address - Fax:952-544-6405
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN198011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical