MEDICARE: DR. GREGORY ALAN NELSON PHD

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	103T00000X	Psychologist	PSY 12389	CA

General Provider Information

NPI Number	:	1497757538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY ALAN NELSON PHD

Provider Business Mailing Address
First Line	:	1617 S PCH HWY
Second Line	:	SUITE F
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5612
Country	:	US
Telephone Number	:	310-540-2061
Fax Number	:	310-540-8550

Provider Business Practice Location Address
First Line	:	1617 S PCH HWY
Second Line	:	SUITE F
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5612
Country	:	US
Telephone Number	:	310-540-2061
Fax Number	:	310-540-8550

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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