Provider Demographics
NPI:1497508949
Name:NELSON, MYAH MAY
Entity Type:Individual
Prefix:
First Name:MYAH
Middle Name:MAY
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 1:3936 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9187
Mailing Address - Country:US
Mailing Address - Phone:608-413-4835
Mailing Address - Fax:
Practice Address - Street 1:3936 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9187
Practice Address - Country:US
Practice Address - Phone:608-413-4825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician