Healthcare Provider Details

I. General information

NPI: 1215545058
Provider Name (Legal Business Name): HEATHER L NELSON EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 BLAKE RD
MOULTONBOROUGH NH
03254-3800
US

IV. Provider business mailing address

PO BOX 419
MOULTONBOROUGH NH
03254-0419
US

V. Phone/Fax

Practice location:
  • Phone: 603-476-4898
  • Fax: 603-476-8009
Mailing address:
  • Phone: 603-476-4898
  • Fax: 603-476-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number66380
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: