1114049772 NPI number — MS. BETH ANN NELSON MSW LICSW

Table of content: MS. BETH ANN NELSON MSW LICSW (NPI 1114049772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114049772 NPI number — MS. BETH ANN NELSON MSW LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
BETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LICSW
Provider Gender Code:
F

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:
1114049772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4660 SLATER ROAD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-4055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-681-8615
Provider Business Mailing Address Fax Number:
651-683-0057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 SLATER ROAD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-4055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-681-8615
Provider Business Practice Location Address Fax Number:
651-683-0057
Provider Enumeration Date:
04/04/2007

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:  04313 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6207092 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40B92NE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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