Provider Demographics
NPI:1417670654
Name:NELSEN, DAYTON JOEL (LMSW)
Entity Type:Individual
Prefix:
First Name:DAYTON
Middle Name:JOEL
Last Name:NELSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1489
Mailing Address - Country:US
Mailing Address - Phone:314-802-2647
Mailing Address - Fax:314-842-2552
Practice Address - Street 1:2650 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1489
Practice Address - Country:US
Practice Address - Phone:314-802-2647
Practice Address - Fax:314-842-2552
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020031628104100000X
MO20220462601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker