Provider Demographics
NPI:1710640032
Name:NELSON, PENELOPE IVY (LADC)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:IVY
Last Name:NELSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:MN
Mailing Address - Zip Code:56098-1052
Mailing Address - Country:US
Mailing Address - Phone:612-877-0276
Mailing Address - Fax:
Practice Address - Street 1:132 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:MN
Practice Address - Zip Code:56098-1052
Practice Address - Country:US
Practice Address - Phone:612-877-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305553101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty