Healthcare Provider Details

I. General information

NPI: 1710452032
Provider Name (Legal Business Name): MICHAEL NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2018
Last Update Date: 10/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 W BETHANY HOME RD
PHOENIX AZ
85015-1935
US

IV. Provider business mailing address

21 N FRASER DR
MESA AZ
85203-8805
US

V. Phone/Fax

Practice location:
  • Phone: 602-774-4745
  • Fax:
Mailing address:
  • Phone: 520-360-9594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: