Healthcare Provider Details

I. General information

NPI: 1417670654
Provider Name (Legal Business Name): DAYTON JOEL NELSEN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 OLIVE ST
SAINT LOUIS MO
63103-1489
US

IV. Provider business mailing address

2650 OLIVE ST
SAINT LOUIS MO
63103-1489
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-2647
  • Fax: 314-842-2552
Mailing address:
  • Phone: 314-802-2647
  • Fax: 314-842-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2020031628
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022046260
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: