Provider Demographics
NPI:1093701542
Name:NELSON, JOHN MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 COLUMBIA AVE STE 2E
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3530
Mailing Address - Country:US
Mailing Address - Phone:219-595-0043
Mailing Address - Fax:219-237-2894
Practice Address - Street 1:9250 COLUMBIA AVE STE 2E
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3530
Practice Address - Country:US
Practice Address - Phone:219-595-0043
Practice Address - Fax:219-237-2894
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000848A101YM0800X, 1041C0700X
IN34000789A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000854OtherBCBSIL
IN408460EMedicare PIN