Provider Demographics
NPI:1083382907
Name:NELSON, CARRIE LYNNE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 GRANDE VALLEY AVE SW UNIT 1522
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3559
Mailing Address - Country:US
Mailing Address - Phone:763-337-2018
Mailing Address - Fax:
Practice Address - Street 1:1470 INDUSTRIAL DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0700
Practice Address - Country:US
Practice Address - Phone:507-353-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician