MEDICARE: JOHN MICHAEL NELSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	39000848A	IN
2	1041C0700X	Clinical Social Worker	39000848A	IN
3	1041C0700X	Clinical Social Worker	34000789A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	90000854	OTHER	IL	BCBSIL

General Provider Information

NPI Number	:	1093701542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MICHAEL NELSON LCSW

Provider Business Mailing Address
First Line	:	9250 COLUMBIA AVE STE 2E
Second Line	:
City	:	MUNSTER
State	:	IN
Zip	:	46321-3530
Country	:	US
Telephone Number	:	219-595-0043
Fax Number	:	219-237-2894

Provider Business Practice Location Address
First Line	:	9250 COLUMBIA AVE STE 2E
Second Line	:
City	:	MUNSTER
State	:	IN
Zip	:	46321-3530
Country	:	US
Telephone Number	:	219-595-0043
Fax Number	:	219-237-2894

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	02/03/2022

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