Provider Demographics
NPI:1417029927
Name:NELSON, JAMES MICHAEL (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MICHAEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 THREE RIVERS N
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1306
Mailing Address - Country:US
Mailing Address - Phone:260-426-8460
Mailing Address - Fax:
Practice Address - Street 1:415 MISSION HILL DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6425
Practice Address - Country:US
Practice Address - Phone:260-431-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003722A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist