Provider Demographics
NPI:1831321520
Name:NELSON, ROSS (PSYD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080A LA AVENIDA ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-1422
Mailing Address - Country:US
Mailing Address - Phone:858-442-6834
Mailing Address - Fax:
Practice Address - Street 1:1080A LA AVENIDA ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1422
Practice Address - Country:US
Practice Address - Phone:858-442-6834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical