Provider Demographics
NPI:1215362009
Name:NELSON, STEPHEN B (LCPC)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:B
Last Name:NELSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1578
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-1578
Mailing Address - Country:US
Mailing Address - Phone:208-278-6807
Mailing Address - Fax:
Practice Address - Street 1:690 S INDUSTRY WAY STE 45
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7907
Practice Address - Country:US
Practice Address - Phone:208-278-6807
Practice Address - Fax:208-493-4885
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5279101Y00000X
IDLCPC-6320101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC-6320Medicaid
IDLPC-5279Medicaid