=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417682022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY APAGALE NELSON PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2022
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6082 KINGSTON DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-7645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-605-4506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6082 KINGSTON DR
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-7645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-605-4506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC013000
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------