Provider Demographics
NPI:1235263344
Name:NELSON, LUCAS JAMES (LICSW)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JAMES
Last Name:NELSON
Suffix:
Gender:M
Credentials:LICSW
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 5196
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5196
Mailing Address - Country:US
Mailing Address - Phone:701-787-8569
Mailing Address - Fax:701-787-5918
Practice Address - Street 1:151 S 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4715
Practice Address - Country:US
Practice Address - Phone:701-787-8569
Practice Address - Fax:701-787-5918
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND43361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054519Medicaid