Provider Demographics
NPI:1609008010
Name:KATHLYN NELSON PHD LLC
Entity Type:Organization
Organization Name:KATHLYN NELSON PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLYN
Authorized Official - Middle Name:ELVERA
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-341-9667
Mailing Address - Street 1:2546 DOROTHY AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4911
Mailing Address - Country:US
Mailing Address - Phone:651-341-9667
Mailing Address - Fax:
Practice Address - Street 1:7616 CURRELL BLVD
Practice Address - Street 2:STE. 280
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2290
Practice Address - Country:US
Practice Address - Phone:651-341-9667
Practice Address - Fax:651-735-7527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3967251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN459510600Medicaid
MN1093804338OtherINDIVIDUAL NATIONAL PROVIDER IDENTIFIER