Provider Demographics
NPI:1821178831
Name:NELSON, MICHAEL JAN (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAN
Last Name:NELSON
Suffix:
Gender:M
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:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-1535
Mailing Address - Country:US
Mailing Address - Phone:715-424-3400
Mailing Address - Fax:715-424-3441
Practice Address - Street 1:420 1ST AVE S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-4157
Practice Address - Country:US
Practice Address - Phone:715-424-3400
Practice Address - Fax:715-424-3441
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1298-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical