Provider Demographics
NPI:1548409584
Name:NELSON, MICHELLE A (MFT, MSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:NELSON
Suffix:
Gender:F
Credentials:MFT, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 MALLARD WAY
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-2563
Mailing Address - Country:US
Mailing Address - Phone:262-264-5673
Mailing Address - Fax:
Practice Address - Street 1:3200 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3252
Practice Address - Country:US
Practice Address - Phone:414-345-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-15
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI136-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist