MEDICARE: REBECCA NELSON LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1124584545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBECCA NELSON LLC

Provider Business Mailing Address
First Line	:	3920 MARLBORO ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-4537
Country	:	US
Telephone Number	:	616-828-8591
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 LAKE EASTBROOK BLVD SE STE 280
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-5940
Country	:	US
Telephone Number	:	616-202-6638
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	REBECCA E NELSON
Credential	:	LMSW
Telephone Number	:	616-202-6638

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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