Healthcare Provider Details

I. General information

NPI: 1649759697
Provider Name (Legal Business Name): KAITLYN ROSE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2785 S BAY ST STE A
EUSTIS FL
32726-6591
US

IV. Provider business mailing address

2785 S BAY ST STE A
EUSTIS FL
32726-6591
US

V. Phone/Fax

Practice location:
  • Phone: 844-668-6222
  • Fax: 888-975-0599
Mailing address:
  • Phone: 844-668-6222
  • Fax: 888-975-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW20420
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW20420
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68353
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: