Provider Demographics
NPI:1720545031
Name:NELSON, CHRISTINA LYNN
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9051 FLORIDA MINING BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1240
Mailing Address - Country:US
Mailing Address - Phone:813-374-2070
Mailing Address - Fax:813-337-0937
Practice Address - Street 1:7333 INTERNATIONAL PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8418
Practice Address - Country:US
Practice Address - Phone:443-742-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-79149247200000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other