Healthcare Provider Details

I. General information

NPI: 1861765992
Provider Name (Legal Business Name): MARK STEVEN NELSON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 PARK AVE UNIT 2 SUITE 8
BURLEY ID
83318-2170
US

IV. Provider business mailing address

238 AVENIDA DEL RIO DR
TWIN FALLS ID
83301-9276
US

V. Phone/Fax

Practice location:
  • Phone: 208-878-3350
  • Fax:
Mailing address:
  • Phone: 208-733-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-31713
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: