Healthcare Provider Details

I. General information

NPI: 1417406877
Provider Name (Legal Business Name): KATHLEEN NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 INTERSTATE DR STE 3
W SPRINGFIELD MA
01089-5100
US

IV. Provider business mailing address

62 CONVERSE ST
LONGMEADOW MA
01106-1110
US

V. Phone/Fax

Practice location:
  • Phone: 774-206-1125
  • Fax:
Mailing address:
  • Phone: 413-636-9751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122720
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: