Provider Demographics
NPI:1306551163
Name:NELSON, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
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 1:14 STRAITS ROCK ROAD
Mailing Address - Street 2:14 STRAITS ROCK ROAD
Mailing Address - City:GAYLORDSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06755
Mailing Address - Country:US
Mailing Address - Phone:203-648-3058
Mailing Address - Fax:
Practice Address - Street 1:14 STRAITS ROCK ROAD
Practice Address - Street 2:14 STRAITS ROCK ROAD
Practice Address - City:GAYLORDSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06755
Practice Address - Country:US
Practice Address - Phone:203-648-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician