Provider Demographics
NPI:1083843593
Name:NELSON, ANGELA RAE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RAE
Other - Last Name:GAWRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18635 37TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-2856
Mailing Address - Country:US
Mailing Address - Phone:763-355-4558
Mailing Address - Fax:763-478-9294
Practice Address - Street 1:1650 W END BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5367
Practice Address - Country:US
Practice Address - Phone:952-856-8452
Practice Address - Fax:952-487-0380
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist