Provider Demographics
NPI:1083824270
Name:NIELSEN, TAY ANGELL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TAY
Middle Name:ANGELL
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:559 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-9506
Mailing Address - Country:US
Mailing Address - Phone:601-932-0958
Mailing Address - Fax:
Practice Address - Street 1:559 CLUBHOUSE DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9506
Practice Address - Country:US
Practice Address - Phone:601-932-0958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC55591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical