Provider Demographics
NPI:1497757538
Name:NELSON, GREGORY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 S PCH HWY
Mailing Address - Street 2:SUITE F
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5612
Mailing Address - Country:US
Mailing Address - Phone:310-540-2061
Mailing Address - Fax:310-540-8550
Practice Address - Street 1:1617 S PCH HWY
Practice Address - Street 2:SUITE F
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5612
Practice Address - Country:US
Practice Address - Phone:310-540-2061
Practice Address - Fax:310-540-8550
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12389103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP 12389Medicare ID - Type Unspecified