Provider Demographics
NPI:1639481484
Name:NELSON, AMY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:SHOEMAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 GULF FWY S STE B
Mailing Address - Street 2:#484
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6769
Mailing Address - Country:US
Mailing Address - Phone:830-911-4274
Mailing Address - Fax:
Practice Address - Street 1:1215 E COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155
Practice Address - Country:US
Practice Address - Phone:830-491-1427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX359981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216058204Medicaid