MEDICARE: CHALICE NELSON LPC

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	101YM0800X	Mental Health Counselor	LPC010728	GA

General Provider Information

NPI Number	:	1972132488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHALICE NELSON LPC

Provider Business Mailing Address
First Line	:	1150 ASTOR AVE SW APT 1310
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-4867
Country	:	US
Telephone Number	:	585-694-7413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1150 ASTOR AVE SW APT 1310
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-4867
Country	:	US
Telephone Number	:	585-694-7413
Fax Number	:

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

Provider Enumeration Date	:	04/06/2020
Last Update Date	:	04/06/2020

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