Provider Demographics
NPI:1083088868
Name:NELSON, GARY (NCC, LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 EDGE LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-2437
Mailing Address - Country:US
Mailing Address - Phone:856-294-8448
Mailing Address - Fax:
Practice Address - Street 1:8008 ROUTE 130 BLDG A
Practice Address - Street 2:STE 206
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-1869
Practice Address - Country:US
Practice Address - Phone:856-294-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00645200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional