Provider Demographics
NPI:1619758745
Name:NELSON, RUBY ANNE I
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:ANNE
Last Name:NELSON
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEATRICE/BEA
Other - Middle Name:ORION
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 CONCORD AVE
Mailing Address - Street 2:#100
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE
Practice Address - Street 2:#100
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician