Healthcare Provider Details

I. General information

NPI: 1811342058
Provider Name (Legal Business Name): KENNETH JAMES NELAN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11514 N PORT WASHINGTON RD STE 101
MEQUON WI
53092-3442
US

IV. Provider business mailing address

11514 N PORT WASHINGTON RD STE 101
MEQUON WI
53092-3442
US

V. Phone/Fax

Practice location:
  • Phone: 414-477-9887
  • Fax: 262-345-7229
Mailing address:
  • Phone: 414-477-9887
  • Fax: 262-345-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: