MEDICARE: DR. CASEY NELSON PSY.D.

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	20041856A	IN
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist	20041856A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750509667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CASEY NELSON PSY.D.

Provider Business Mailing Address
First Line	:	1515 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1533
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1533
Country	:	US
Telephone Number	:	260-408-1085
Fax Number	:

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	12/12/2008

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