=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093436941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY NELSON LICSW, LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2022
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1809 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-441-7000
-----------------------------------------------------
Fax | 320-441-7005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1809 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-441-7000
-----------------------------------------------------
Fax | 320-441-7005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 30426
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 32165
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------