Healthcare Provider Details

I. General information

NPI: 1144457326
Provider Name (Legal Business Name): MICHAEL N. NELSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 WEST CONGRESS PARKWAY 1228 KELLOGG
CHICAGO IL
60612
US

IV. Provider business mailing address

1653 WEST CONGRESS PARKWAY 1223 KELLOGG BUILDING
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6656
  • Fax: 312-942-8592
Mailing address:
  • Phone: 312-942-6656
  • Fax: 312-942-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.003181
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-003181
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071.003181
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071.003181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: