Provider Demographics
NPI:1215545058
Name:NELSON, HEATHER L (EDS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:EDS
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 419
Mailing Address - Street 2:
Mailing Address - City:MOULTONBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03254-0419
Mailing Address - Country:US
Mailing Address - Phone:603-476-4898
Mailing Address - Fax:603-476-8009
Practice Address - Street 1:25 BLAKE RD
Practice Address - Street 2:
Practice Address - City:MOULTONBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03254-3800
Practice Address - Country:US
Practice Address - Phone:603-476-4898
Practice Address - Fax:603-476-8009
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH66380103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool