Provider Demographics
NPI:1376327593
Name:NELSON, MIA ROSE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ROSE
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 1:8119 PARK VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-2131
Mailing Address - Country:US
Mailing Address - Phone:402-881-1767
Mailing Address - Fax:
Practice Address - Street 1:14301 FNB PKWY
Practice Address - Street 2:STE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-7200
Practice Address - Country:US
Practice Address - Phone:402-807-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician