Provider Demographics
NPI:1114326998
Name:NILSEN, DAVID THOMAS
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:NILSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 FEATHERSTONE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6300
Mailing Address - Country:US
Mailing Address - Phone:815-227-0081
Mailing Address - Fax:815-387-5316
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-347-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL1490232081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker