Provider Demographics
NPI:1285109314
Name:NELSON, LANTRELLE L
Entity type:Individual
Prefix:
First Name:LANTRELLE
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70087-0612
Mailing Address - Country:US
Mailing Address - Phone:504-401-1530
Mailing Address - Fax:
Practice Address - Street 1:203 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4203
Practice Address - Country:US
Practice Address - Phone:504-401-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty