Provider Demographics
NPI:1760193346
Name:NELSON, CARLY (ATR-BC, LPC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 BATHURST DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-8252
Mailing Address - Country:US
Mailing Address - Phone:516-417-1054
Mailing Address - Fax:
Practice Address - Street 1:608 BATHURST DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8252
Practice Address - Country:US
Practice Address - Phone:516-417-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
21-088221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist