Healthcare Provider Details

I. General information

NPI: 1639280092
Provider Name (Legal Business Name): TERI NELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 S CARAWAY RD SUITE M
JONESBORO AR
72401-6204
US

IV. Provider business mailing address

1600 ALDERSGATE RD SUITE 200
LITTLE ROCK AR
72205-6676
US

V. Phone/Fax

Practice location:
  • Phone: 870-910-3757
  • Fax: 870-910-4999
Mailing address:
  • Phone: 501-661-0720
  • Fax: 501-325-7938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1558-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5095-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: