Provider Demographics
NPI:1265089320
Name:NELSON, KENYA NICOLE
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:NICOLE
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 1:1228 FLOWER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75134-1662
Mailing Address - Country:US
Mailing Address - Phone:469-265-5603
Mailing Address - Fax:
Practice Address - Street 1:1203 S CLARK RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3242
Practice Address - Country:US
Practice Address - Phone:972-291-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA186361041C0700X
TX614441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty