Provider Demographics
NPI:1588650089
Name:NELSON, ELLEN P (MED)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:P
Last Name:NELSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8490 MUKILTEO SPEEDWAY
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-3206
Mailing Address - Country:US
Mailing Address - Phone:425-423-8116
Mailing Address - Fax:425-356-6515
Practice Address - Street 1:8490 MUKILTEO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-3206
Practice Address - Country:US
Practice Address - Phone:425-423-8116
Practice Address - Fax:425-356-6515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001339106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist