Provider Demographics
NPI:1740806330
Name:NELSON, BRIANNA MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MICHELLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-746-4097
Mailing Address - Fax:208-746-2294
Practice Address - Street 1:1720 18TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-746-4097
Practice Address - Fax:208-746-4097
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11884101YA0400X
CADC-11884101YA0400X
IDLMSW-41403104100000X, 1041C0700X
LMSW-41403104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical