Provider Demographics
NPI:1114049772
Name:NELSON, BETH ANN (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 SLATER ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4055
Mailing Address - Country:US
Mailing Address - Phone:651-681-8615
Mailing Address - Fax:651-683-0057
Practice Address - Street 1:4660 SLATER ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4055
Practice Address - Country:US
Practice Address - Phone:651-681-8615
Practice Address - Fax:651-683-0057
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN043131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
6207092OtherMEDICA
MN40B92NEOtherBLUE CROSS BLUE SHIELD