Provider Demographics
NPI:1588614846
Name:NELSON, BUTLER (PHD)
Entity Type:Individual
Prefix:DR
First Name:BUTLER
Middle Name:
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 1:1400 PINNACLE CT
Mailing Address - Street 2:#203
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-4199
Mailing Address - Country:US
Mailing Address - Phone:510-548-8980
Mailing Address - Fax:510-374-6777
Practice Address - Street 1:2931 SHATTUCK AVE
Practice Address - Street 2:SUITE 101E
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:510-548-8980
Practice Address - Fax:510-374-6777
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT12314101YM0800X, 106H00000X
CAPSY13930103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL13930Medicare UPIN