1215121009 NPI number — MR. SCOTT G NELSON LCSW

Table of content: MR. SCOTT G NELSON LCSW (NPI 1215121009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215121009 NPI number — MR. SCOTT G NELSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
SCOTT
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215121009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 OLD RIDGEBURY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06810-5128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-792-4515
Provider Business Mailing Address Fax Number:
203-748-2632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 MEADOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-1807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-597-0643
Provider Business Practice Location Address Fax Number:
203-597-0834
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  007750 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004123840 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004257516 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008017939 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008031626 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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