Provider Demographics
NPI:1770853301
Name:KIMBERLY D NIELSEN, PLLC
Entity Type:Organization
Organization Name:KIMBERLY D NIELSEN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:623-640-7940
Mailing Address - Street 1:15396 N 83RD AVE STE F101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5629
Mailing Address - Country:US
Mailing Address - Phone:623-640-7940
Mailing Address - Fax:
Practice Address - Street 1:15396 N 83RD AVE STE F101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5629
Practice Address - Country:US
Practice Address - Phone:623-640-7940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW10991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1922143833OtherINDIVIDUAL