Provider Demographics
NPI:1346419561
Name:NELSON, SHELLY R (LPC, CSW, CSAC)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPC, CSW, CSAC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:HODSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2825 N MAYFAIR RD STE 209
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4406
Mailing Address - Country:US
Mailing Address - Phone:414-630-1028
Mailing Address - Fax:414-256-0070
Practice Address - Street 1:2825 N MAYFAIR RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4406
Practice Address - Country:US
Practice Address - Phone:414-630-1028
Practice Address - Fax:414-256-0070
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2620-120104100000X
WI3990-125101YP2500X
WI16032-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43731400Medicaid