Provider Demographics
NPI:1164414033
Name:NELSON, SCOTT MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 LBJ FWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6467
Mailing Address - Country:US
Mailing Address - Phone:972-233-6301
Mailing Address - Fax:972-991-8966
Practice Address - Street 1:6330 LBJ FWY
Practice Address - Street 2:SUITE 150
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6467
Practice Address - Country:US
Practice Address - Phone:972-233-6301
Practice Address - Fax:972-991-8966
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32145103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1684631Medicaid
TX610865Medicare ID - Type Unspecified