Provider Demographics
NPI:1700367604
Name:NELSON, LILINE (BEHAVIOR HEALTH)
Entity Type:Individual
Prefix:
First Name:LILINE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:BEHAVIOR HEALTH
Other - Prefix:
Other - First Name:LILINE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:2604 NW 3RD AVE APT 227
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3047
Mailing Address - Country:US
Mailing Address - Phone:954-240-9324
Mailing Address - Fax:
Practice Address - Street 1:2604 NW 3RD AVE APT 227
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-3047
Practice Address - Country:US
Practice Address - Phone:954-240-9324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9437850356Medicaid