Healthcare Provider Details

I. General information

NPI: 1871006478
Provider Name (Legal Business Name): AMBER L NELSON SSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 E AVENUE L
LEWISTOWN IL
61542-9454
US

IV. Provider business mailing address

15501 E AVENUE L
LEWISTOWN IL
61542-9454
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-2231
  • Fax:
Mailing address:
  • Phone: 309-547-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number382924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: