Healthcare Provider Details

I. General information

NPI: 1750094736
Provider Name (Legal Business Name): KIRSTEN NELSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 OLD SANTA FE TRL APT B
SANTA FE NM
87505-0404
US

IV. Provider business mailing address

644 OLD SANTA FE TRL APT B
SANTA FE NM
87505-0404
US

V. Phone/Fax

Practice location:
  • Phone: 575-224-1077
  • Fax:
Mailing address:
  • Phone: 575-224-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN NELSON
Title or Position: OWNER
Credential: MA, LPCC
Phone: 575-224-1077