Provider Demographics
NPI:1245358035
Name:NELSON, KENDALL R (MA,LMFT, LCSW)
Entity type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:R
Last Name:NELSON
Suffix:
Gender:M
Credentials:MA,LMFT, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 45
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47665-9705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1843
Practice Address - Country:US
Practice Address - Phone:812-386-7966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003111A1041C0700X
IN35000054A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist