Provider Demographics
NPI:1073665501
Name:NELSON, TODD MICHAEL (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E GROVE ST
Mailing Address - Street 2:SUITE R.
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4200
Mailing Address - Country:US
Mailing Address - Phone:309-532-3104
Mailing Address - Fax:
Practice Address - Street 1:901 E GROVE ST
Practice Address - Street 2:SUITE T.
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4200
Practice Address - Country:US
Practice Address - Phone:309-532-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003983101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health