Provider Demographics
NPI:1235141938
Name:NELSON, LINDA CAROL (MA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:CAROL
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17306 CALICO HILL RD
Mailing Address - Street 2:
Mailing Address - City:ALTURA
Mailing Address - State:MN
Mailing Address - Zip Code:55910-4223
Mailing Address - Country:US
Mailing Address - Phone:612-379-2640
Mailing Address - Fax:612-379-2820
Practice Address - Street 1:4101 HARRIET AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1442
Practice Address - Country:US
Practice Address - Phone:612-379-2640
Practice Address - Fax:612-379-2820
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1274103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN985250600Medicaid