Basic Information
| Provider Information | |||||||||
| NPI: | 1396886743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MA.,LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1448 WELLESLEY DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480436517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864652628 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 46360 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480512800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869480224 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301007186 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.