Provider Demographics
NPI:1215078803
Name:NELSON, AMY MARIE (LMHC)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 WOODWARD RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-9674
Mailing Address - Country:US
Mailing Address - Phone:904-343-8657
Mailing Address - Fax:
Practice Address - Street 1:11820 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6670
Practice Address - Country:US
Practice Address - Phone:904-642-9100
Practice Address - Fax:904-642-9108
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9003104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker