Healthcare Provider Details

I. General information

NPI: 1992111470
Provider Name (Legal Business Name): JOHN NELSON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W BLDG 1040
JBSA RANDOLPH TX
78150-4800
US

IV. Provider business mailing address

221 3RD ST W BLDG 1040
JBSA RANDOLPH TX
78150-4800
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-2448
  • Fax:
Mailing address:
  • Phone: 210-652-2448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: