Provider Demographics
NPI:1609354547
Name:NELSON, MICHAEL RICHARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 121
Mailing Address - Street 2:
Mailing Address - City:CORINNE
Mailing Address - State:UT
Mailing Address - Zip Code:84307-0121
Mailing Address - Country:US
Mailing Address - Phone:801-941-0489
Mailing Address - Fax:
Practice Address - Street 1:663 W 950 S
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302
Practice Address - Country:US
Practice Address - Phone:435-734-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker