Provider Demographics
NPI:1760935381
Name:NELSON, LERRLYN (PHD)
Entity Type:Individual
Prefix:
First Name:LERRLYN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18833 DWYER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2607
Mailing Address - Country:US
Mailing Address - Phone:313-515-5380
Mailing Address - Fax:
Practice Address - Street 1:17101 ALBION ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3808
Practice Address - Country:US
Practice Address - Phone:313-515-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18563101YP1600X, 101YP2500X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional