Healthcare Provider Details

I. General information

NPI: 1255030425
Provider Name (Legal Business Name): CARLY CLEGG NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 MIDDLETON ST UNIT B
BEAUFORT SC
29902-5611
US

IV. Provider business mailing address

1105B MIDDLETON ST STE B
BEAUFORT SC
29902-5358
US

V. Phone/Fax

Practice location:
  • Phone: 843-379-3444
  • Fax: 843-379-3449
Mailing address:
  • Phone: 843-379-3444
  • Fax: 843-379-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-79181
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: