Healthcare Provider Details

I. General information

NPI: 1083605794
Provider Name (Legal Business Name): MICHELLE NELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3458 NEELY RD
MC GUIRE AFB NJ
08641-5312
US

IV. Provider business mailing address

3458 NEELY RD
MC GUIRE AFB NJ
08641-5312
US

V. Phone/Fax

Practice location:
  • Phone: 609-754-9448
  • Fax:
Mailing address:
  • Phone: 609-754-9448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00214700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: