Healthcare Provider Details

I. General information

NPI: 1104977990
Provider Name (Legal Business Name): RONALD J NELSON ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 N. BISBEE AVE
WILLCOX AZ
85643
US

IV. Provider business mailing address

PO BOX 2965
FLORENCE AZ
85232-2965
US

V. Phone/Fax

Practice location:
  • Phone: 520-384-4211
  • Fax: 520-868-5254
Mailing address:
  • Phone: 520-868-5254
  • Fax: 520-868-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: