Provider Demographics
NPI:1174628598
Name:NELSON, LAURA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 NAPA AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2607
Mailing Address - Country:US
Mailing Address - Phone:510-725-9240
Mailing Address - Fax:
Practice Address - Street 1:406 COLUSA AVE.
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530
Practice Address - Country:US
Practice Address - Phone:510-725-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11575832OtherCAQH
PA049848Medicare ID - Type Unspecified