Provider Demographics
NPI:1205368503
Name:NELSON, DEBORAH ANN KANN (CADC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN KANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2518
Mailing Address - Country:US
Mailing Address - Phone:570-321-7860
Mailing Address - Fax:
Practice Address - Street 1:1536 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2518
Practice Address - Country:US
Practice Address - Phone:570-321-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3803101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013628760001Medicaid