=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740294933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE R NELSON PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 05/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10921 WILSHIRE BLVD SUITE 1206
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-963-4891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10921 WILSHIRE BLVD SUITE 1206
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-963-4891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY18659
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------