Healthcare Provider Details

I. General information

NPI: 1730274713
Provider Name (Legal Business Name): ROBERT C NELSON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5617 MAXWELL PL
WILMINGTON NC
28409-2966
US

IV. Provider business mailing address

PO BOX 16310
WILMINGTON NC
28408-6310
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-742-9243
  • Fax: 888-746-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1210
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberRPS2002005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: