Provider Demographics
NPI:1558644351
Name:NELSON, GARY W (MSW, LCSW, CSAYC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSW, LCSW, CSAYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5638 PROFESSIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-5042
Mailing Address - Country:US
Mailing Address - Phone:317-247-8900
Mailing Address - Fax:317-247-8935
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5042
Practice Address - Country:US
Practice Address - Phone:317-247-8900
Practice Address - Fax:317-247-8935
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006899A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical