Basic Information
| Provider Information | |||||||||
| NPI: | 1992429294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4930 S SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741455712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924008 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4930 S SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741455712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924008 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2022 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10912 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.