Provider Demographics
NPI:1356407167
Name:NELSON, KATHLEEN ANN (MS)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 SOURDOUGH RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-9260
Mailing Address - Country:US
Mailing Address - Phone:406-579-8499
Mailing Address - Fax:
Practice Address - Street 1:420 W MENDENHALL ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3449
Practice Address - Country:US
Practice Address - Phone:406-587-1181
Practice Address - Fax:406-587-1801
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0255374Medicaid
MT000744813OtherBCBS