Provider Demographics
NPI:1023207099
Name:NELSON, ROGER W (MS, LISAC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:MS, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15170 N HAYDEN RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2571
Mailing Address - Country:US
Mailing Address - Phone:480-991-2200
Mailing Address - Fax:
Practice Address - Street 1:15170 N HAYDEN RD
Practice Address - Street 2:SUITE 4
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2571
Practice Address - Country:US
Practice Address - Phone:480-991-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC - 1252101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)