Provider Demographics
NPI:1548407919
Name:NELSON, TIESHA SIMONA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIESHA
Middle Name:SIMONA
Last Name:NELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8360 W OAKLAND PARK BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7339
Mailing Address - Country:US
Mailing Address - Phone:954-546-4677
Mailing Address - Fax:954-246-4996
Practice Address - Street 1:8360 W OAKLAND PARK BLVD STE 303
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7339
Practice Address - Country:US
Practice Address - Phone:954-546-4677
Practice Address - Fax:941-328-3575
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7781103TA0400X, 103TC0700X, 103TF0200X
FLPY 7781103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106660500Medicaid