Provider Demographics
NPI:1366483489
Name:NELSON, LINDA D (PHD, ABPN)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHD, ABPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-825-6429
Mailing Address - Fax:310-206-5061
Practice Address - Street 1:35 S RAYMOND AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1931
Practice Address - Country:US
Practice Address - Phone:626-304-9960
Practice Address - Fax:626-304-9995
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY106882084P0804X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY106880OtherMEDICAL
CACP10688CMedicare PIN
CACP10688DMedicare PIN