Healthcare Provider Details

I. General information

NPI: 1154257814
Provider Name (Legal Business Name): NATHANIEL FOREVER NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4319 PIEDMONT AVE
OAKLAND CA
94611-4755
US

IV. Provider business mailing address

3408 RICHMOND BLVD APT 206
OAKLAND CA
94611-5853
US

V. Phone/Fax

Practice location:
  • Phone: 847-924-2751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: