Basic Information
| Provider Information | |||||||||
| NPI: | 1477171304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | KIRA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 S MILLIKEN AVE STE 508 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917612337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099832020 | ||||||||
| FaxNumber: | 9099665205 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 S MILLIKEN AVE STE 508 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917612337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099832020 | ||||||||
| FaxNumber: | 9099665205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2020 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 128213 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.