Provider Demographics
NPI:1568652659
Name:SUSAN C, NELSON
Entity Type:Organization
Organization Name:SUSAN C, NELSON
Other - Org Name:BLUE RIDGE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:COLLETTE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:530-647-1763
Mailing Address - Street 1:PO BOX 1091
Mailing Address - Street 2:
Mailing Address - City:POLLOCK PINES
Mailing Address - State:CA
Mailing Address - Zip Code:95726-1091
Mailing Address - Country:US
Mailing Address - Phone:530-647-1763
Mailing Address - Fax:530-647-1763
Practice Address - Street 1:4535 MISSOURI FLAT RD
Practice Address - Street 2:SUITE 200 C
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6846
Practice Address - Country:US
Practice Address - Phone:530-647-1763
Practice Address - Fax:530-647-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 21304251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06547ZMedicare UPIN