Provider Demographics
NPI:1710594783
Name:STORY-NELSON, SHIRLEY L (LCSW, LMFT, LCAC)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:L
Last Name:STORY-NELSON
Suffix:
Gender:F
Credentials:LCSW, LMFT, LCAC
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:L
Other - Last Name:CARNEYGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4956 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4609
Mailing Address - Country:US
Mailing Address - Phone:219-895-4830
Mailing Address - Fax:
Practice Address - Street 1:4956 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4609
Practice Address - Country:US
Practice Address - Phone:219-895-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001161A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical