Healthcare Provider Details

I. General information

NPI: 1730311457
Provider Name (Legal Business Name): ALICE L NELSON CMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 HACIENDA AVE
HATTIESBURG MS
39402-1828
US

IV. Provider business mailing address

410 HACIENDA AVE
HATTIESBURG MS
39402-1828
US

V. Phone/Fax

Practice location:
  • Phone: 601-705-1901
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0784
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: