Provider Demographics
NPI:1629061221
Name:NELSON, CONNIE LEE (MA QMHP LPCMH CCDC)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:LEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA QMHP LPCMH CCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 S BROWN PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6582
Mailing Address - Country:US
Mailing Address - Phone:605-332-1700
Mailing Address - Fax:605-336-9031
Practice Address - Street 1:2210 S BROWN PLACE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-332-1700
Practice Address - Fax:605-336-9031
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
45265101Y00000X
SD9605696101YA0400X
ICADC2245101YA0400X
SDLPCMH2116101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6576132Medicaid