Healthcare Provider Details

I. General information

NPI: 1104685460
Provider Name (Legal Business Name): MYLES NELSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ACER LOOP
NAMPA ID
83687-1098
US

IV. Provider business mailing address

1665 SENDERO LN
SANTA ROSA CA
95407-8408
US

V. Phone/Fax

Practice location:
  • Phone: 661-621-5859
  • Fax:
Mailing address:
  • Phone: 208-617-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8911516
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: