Basic Information
| Provider Information | |||||||||
| NPI: | 1407373970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | QUA'DAYSHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 289 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176765405 | ||||||||
| FaxNumber: | 5176765460 | ||||||||
| Practice Location | |||||||||
| Address1: | G3169 BEECHER RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102370799 | ||||||||
| FaxNumber: | 8102340953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2017 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6851102860 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 6802089685 | MI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.