Healthcare Provider Details

I. General information

NPI: 1437552130
Provider Name (Legal Business Name): MARLA NELSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 03/15/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 VINE ST
MORO IL
62067-1703
US

IV. Provider business mailing address

237 VINE ST
MORO IL
62067-1703
US

V. Phone/Fax

Practice location:
  • Phone: 618-823-7403
  • Fax:
Mailing address:
  • Phone: 618-823-7403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.009435
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: