Provider Demographics
NPI:1235633181
Name:NELSON, CYNTHIA SUE (LPC)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:SUE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 W GRANDE MARKET DR
Mailing Address - Street 2:SUITE M
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913
Mailing Address - Country:US
Mailing Address - Phone:920-381-0103
Mailing Address - Fax:866-635-1605
Practice Address - Street 1:5601 W GRANDE MARKET DR
Practice Address - Street 2:SUITE M
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:920-381-0103
Practice Address - Fax:866-635-1605
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6538101YP2500X
WI6538-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100075977Medicaid