Provider Demographics
NPI:1083904700
Name:NELSON, AMY K (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 N LAKE PARKER AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2040
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:863-733-4496
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW11248104100000X, 104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008428900Medicaid
FL003556600Medicaid
FL008428900Medicaid