=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598156168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDA NELSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2015
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5165 JUPITER INLET WAY
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13215-1973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-377-2354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5165 JUPITER INLET WAY
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13215-1973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-377-2354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDA NELSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 607-377-2354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------