Provider Demographics
NPI:1811396542
Name:NELSON, CLINTON (LBS)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13062 TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1001
Mailing Address - Country:US
Mailing Address - Phone:267-973-7843
Mailing Address - Fax:
Practice Address - Street 1:13062 TOWNSEND RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-1001
Practice Address - Country:US
Practice Address - Phone:267-973-7843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000846103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst