Provider Demographics
NPI:1114438058
Name:NELSON, HENRIETTA MAE
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:MAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HENRIETTA
Other - Middle Name:M
Other - Last Name:STANDS-NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7376
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-1376
Mailing Address - Country:US
Mailing Address - Phone:505-918-3167
Mailing Address - Fax:
Practice Address - Street 1:400 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5833
Practice Address - Country:US
Practice Address - Phone:405-659-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker