Provider Demographics
NPI:1326473281
Name:NELSON, CINDY L
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 FOREST RIDGE CT APT 202
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3376
Mailing Address - Country:US
Mailing Address - Phone:801-450-5704
Mailing Address - Fax:
Practice Address - Street 1:366 E GRAVES AVE STE D
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-5266
Practice Address - Country:US
Practice Address - Phone:386-775-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLMH15186101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program