Provider Demographics
NPI:1093436941
Name:NELSON, MISTY (LADC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-2627
Mailing Address - Country:US
Mailing Address - Phone:320-214-7744
Mailing Address - Fax:
Practice Address - Street 1:309 7TH ST NW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-2627
Practice Address - Country:US
Practice Address - Phone:320-214-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30426101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)