Provider Demographics
NPI:1245825306
Name:NELSON, KATE RENAE
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:RENAE
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 1:755 GRIFFIN CT APT C
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-2283
Mailing Address - Country:US
Mailing Address - Phone:651-491-3071
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR STE 1&2
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2339
Practice Address - Country:US
Practice Address - Phone:612-445-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician