Provider Demographics
NPI:1760574792
Name:NELSON, TERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 HIGHWAY 51 STE D
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2136
Mailing Address - Country:US
Mailing Address - Phone:601-707-5023
Mailing Address - Fax:601-707-5068
Practice Address - Street 1:665 HIGHWAY 51 STE D
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2136
Practice Address - Country:US
Practice Address - Phone:601-707-5023
Practice Address - Fax:601-707-5068
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC07901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02651769Medicaid