Provider Demographics
NPI:1417714965
Name:NELSON, JANETTE (LISAC)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 MCCULLOCH BLVD N STE D140
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5749
Mailing Address - Country:US
Mailing Address - Phone:928-486-2188
Mailing Address - Fax:
Practice Address - Street 1:151 RIVIERA DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5740
Practice Address - Country:US
Practice Address - Phone:928-855-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ155301101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)