Healthcare Provider Details

I. General information

NPI: 1225260631
Provider Name (Legal Business Name): LARRY NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 HAIGHT ST
SAN FRANCISCO CA
94102-6127
US

IV. Provider business mailing address

4764 BELFAST AVE
OAKLAND CA
94619-3019
US

V. Phone/Fax

Practice location:
  • Phone: 415-554-1480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: