MEDICARE: DR. W. MICHAEL NELSON III 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	103TC0700X	Clinical Psychologist	2734	OH

General Provider Information

NPI Number	:	1497811913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. W. MICHAEL NELSON III PHD

Provider Business Mailing Address
First Line	:	DEPARTMENT OF PSYCHOLOGY, XAVIER UNIVERSTIY
Second Line	:	3800 VICTORY PARKWAY
City	:	CINCINNATI
State	:	OH
Zip	:	45207-6411
Country	:	US
Telephone Number	:	513-745-3298
Fax Number	:	513-745-4380

Provider Business Practice Location Address
First Line	:	DEPARTMENT OF PSYCHLOGY, XAVIER UNIVERSITY
Second Line	:	3800 VICTORY PARKWAY
City	:	CINCINNATI
State	:	OH
Zip	:	45207-6411
Country	:	US
Telephone Number	:	513-745-3298
Fax Number	:	513-745-4380

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

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	07/08/2007

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