Provider Demographics
NPI:1003197567
Name:NELSON, DENNIS (BS, LADC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:BS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 SIOUX TRL NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9077
Mailing Address - Country:US
Mailing Address - Phone:952-496-6164
Mailing Address - Fax:
Practice Address - Street 1:2330 SIOUX TRL NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-9077
Practice Address - Country:US
Practice Address - Phone:952-496-6164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300740101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)