Provider Demographics
NPI:1689966582
Name:NELSON, KATHLEEN ELIZAETH (AA)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELIZAETH
Last Name:NELSON
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 PETERSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2606
Mailing Address - Country:US
Mailing Address - Phone:360-856-3054
Mailing Address - Fax:360-856-3065
Practice Address - Street 1:614 PETERSON RD STE 200
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2606
Practice Address - Country:US
Practice Address - Phone:360-856-3054
Practice Address - Fax:360-856-3065
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WACG602205094175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor