Provider Demographics
NPI:1346076882
Name:NELSON, MARK (MSMFT, RMFTI)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSMFT, RMFTI
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 1471
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30086-1471
Mailing Address - Country:US
Mailing Address - Phone:678-243-0822
Mailing Address - Fax:
Practice Address - Street 1:3038 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1493
Practice Address - Country:US
Practice Address - Phone:305-317-5596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT4141106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist