Healthcare Provider Details

I. General information

NPI: 1902086168
Provider Name (Legal Business Name): GORDON E NIELSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520B ROCK ISLAND RD
EAST WENATCHEE WA
98802-5844
US

IV. Provider business mailing address

2520-B ROCK ISLAND RD.
EAST WENATCHEE WA
98802
US

V. Phone/Fax

Practice location:
  • Phone: 509-470-8544
  • Fax: 509-470-8544
Mailing address:
  • Phone: 509-470-8544
  • Fax: 509-470-8544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00009599
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: