=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619532983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTIN DANIELLE NELSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2019
-----------------------------------------------------
Last Update Date | 05/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4080 CENTRE ST STE 105
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-2655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-357-6606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2635 B ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92102-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-905-9659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 74428
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------