Provider Demographics
NPI:1609380997
Name:NELSON, KIM DENISE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DENISE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18703 BRADY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1706
Mailing Address - Country:US
Mailing Address - Phone:313-721-7427
Mailing Address - Fax:
Practice Address - Street 1:29260 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1161
Practice Address - Country:US
Practice Address - Phone:248-701-9691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012419101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional