Healthcare Provider Details

I. General information

NPI: 1508797952
Provider Name (Legal Business Name): BENJAMIN WADE NELSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BENJAMIN WADE FLANNERY NELSON PHD

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 ELDORADO DR
SUPERIOR CO
80027-8203
US

IV. Provider business mailing address

2032 ELDORADO DR
SUPERIOR CO
80027-8203
US

V. Phone/Fax

Practice location:
  • Phone: 310-801-4595
  • Fax:
Mailing address:
  • Phone: 310-801-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSYC.PY.61249518
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: