Healthcare Provider Details

I. General information

NPI: 1427928050
Provider Name (Legal Business Name): MARY LEE NELSON PHD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10311 FOREST BROOK LN APT D
SAINT LOUIS MO
63146-5844
US

IV. Provider business mailing address

10311 FOREST BROOK LN APT D
SAINT LOUIS MO
63146-5844
US

V. Phone/Fax

Practice location:
  • Phone: 775-990-3106
  • Fax:
Mailing address:
  • Phone: 775-990-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2010009608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: