Basic Information
| Provider Information | |||||||||
| NPI: | 1992942619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | MALCOLM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 WADSWORTH STREET | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605271124 | ||||||||
| FaxNumber: | 8607242539 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 WADSWORTH STREET | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605271124 | ||||||||
| FaxNumber: | 8607242539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2009 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.