Provider Demographics
NPI:1134279227
Name:NELSON, LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 135621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherMEDICARE GROUP ID#
CAZZZ92073ZOtherMEDICARE GROUP ID#
CAZZZ92069ZOtherMEDICARE GROUP ID#
CALCSW 13562OtherLICENSE #
CAZZZ91891ZOtherMEDICARE GROUP ID#
CAZZZ91892ZOtherMEDICARE GROUP ID#
CAQ49540Medicare UPIN