Provider Demographics
NPI:1598209033
Name:NELSON-JOHNSON, IAN (PSYD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:NELSON-JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6649 ODANA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1011
Mailing Address - Country:US
Mailing Address - Phone:847-736-2917
Mailing Address - Fax:
Practice Address - Street 1:6649 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1011
Practice Address - Country:US
Practice Address - Phone:847-736-2917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IA092237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor