Provider Demographics
NPI:1609951946
Name:NELSON, BRUCE ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
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 1:1500 MCANDREWS RD W
Mailing Address - Street 2:STE 240
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4432
Mailing Address - Country:US
Mailing Address - Phone:952-892-8436
Mailing Address - Fax:952-892-8451
Practice Address - Street 1:1500 MCANDREWS RD W
Practice Address - Street 2:STE 240
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4432
Practice Address - Country:US
Practice Address - Phone:952-892-8436
Practice Address - Fax:952-892-8451
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5060583-00Medicaid
MN680001842Medicare ID - Type UnspecifiedMEDICARE ID NUMBER