Provider Demographics
NPI:1194044040
Name:NELSON, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 N 550 E
Mailing Address - Street 2:
Mailing Address - City:FIRTH
Mailing Address - State:ID
Mailing Address - Zip Code:83236-1123
Mailing Address - Country:US
Mailing Address - Phone:208-681-5067
Mailing Address - Fax:
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7519
Practice Address - Country:US
Practice Address - Phone:208-522-9812
Practice Address - Fax:208-522-9859
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW29364104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806647900Medicaid