Provider Demographics
NPI:1063609733
Name:NELSON, RENELLE E (MFT)
Entity type:Individual
Prefix:MS
First Name:RENELLE
Middle Name:E
Last Name:NELSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 W BROWN DEER RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2311
Mailing Address - Country:US
Mailing Address - Phone:414-355-5594
Mailing Address - Fax:414-751-5166
Practice Address - Street 1:5600 W BROWN DEER RD
Practice Address - Street 2:SUITE 216
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-2311
Practice Address - Country:US
Practice Address - Phone:414-355-5594
Practice Address - Fax:414-751-5166
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43712700Medicaid