Provider Demographics
NPI:1740770593
Name:NELSON, REBECCA K
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEMORIAL MEDICAL CENTER
Mailing Address - Street 2:1635 MAPLE LANE
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-5400
Mailing Address - Fax:715-685-5102
Practice Address - Street 1:MEMORIAL MEDICAL CENTER
Practice Address - Street 2:1635 MAPLE LANE
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-5400
Practice Address - Fax:715-685-5102
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16172OtherWI LICENSE