Provider Demographics
NPI:1073299582
Name:NELSON, MYESHA RAVEN DANIELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MYESHA
Middle Name:RAVEN DANIELLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2929
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:6151-6153 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4598
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-389-3599
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ214171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical