Provider Demographics
NPI:1790538882
Name:NELSON, MIRIAM (RBT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12086 FORT CAROLINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2688
Mailing Address - Country:US
Mailing Address - Phone:904-415-1609
Mailing Address - Fax:
Practice Address - Street 1:12086 FORT CAROLINE RD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2688
Practice Address - Country:US
Practice Address - Phone:904-415-1609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT22220207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty