Provider Demographics
NPI:1770854168
Name:NELSON, MARY JANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
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 1:3381 MAYFLOWER WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2994
Mailing Address - Country:US
Mailing Address - Phone:801-331-6775
Mailing Address - Fax:801-766-2010
Practice Address - Street 1:3381 MAYFLOWER WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2994
Practice Address - Country:US
Practice Address - Phone:801-331-6775
Practice Address - Fax:801-766-2010
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5172018-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical