Provider Demographics
NPI:1053457853
Name:NELSON, TINA D
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:DANITTE
Other - Last Name:UPSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 LONG CANE RDG
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7260
Mailing Address - Country:US
Mailing Address - Phone:706-504-5350
Mailing Address - Fax:
Practice Address - Street 1:USS KEARSARGE LHD 3
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09534
Practice Address - Country:US
Practice Address - Phone:757-443-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013290104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker