Provider Demographics
NPI:1134484876
Name:NELSON, BENJAMIN (MA, BHT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:MA, BHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4372 E SACK DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-3395
Mailing Address - Country:US
Mailing Address - Phone:480-326-4233
Mailing Address - Fax:
Practice Address - Street 1:4372 E SACK DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3395
Practice Address - Country:US
Practice Address - Phone:480-326-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3856919385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child