MEDICARE: MS. TINA MARIA NELSON LCSW

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	711	AK

General Provider Information

NPI Number	:	1831167428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA MARIA NELSON LCSW

Provider Business Mailing Address
First Line	:	130 PARKER VILLAGE CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-6750
Country	:	US
Telephone Number	:	850-283-7511
Fax Number	:	850-283-7721

Provider Business Practice Location Address
First Line	:	340 MAGNOLIA CIR
Second Line	:
City	:	TYNDALL A F B
State	:	FL
Zip	:	32403-5604
Country	:	US
Telephone Number	:	850-283-7511
Fax Number	:	850-283-7721

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/08/2007

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