Provider Demographics
NPI:1851651400
Name:LINDA D. NELSON, PH.D., ABPN, INC.
Entity Type:Organization
Organization Name:LINDA D. NELSON, PH.D., ABPN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPN
Authorized Official - Phone:310-458-4581
Mailing Address - Street 1:1137 2ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5068
Mailing Address - Country:US
Mailing Address - Phone:310-458-4581
Mailing Address - Fax:
Practice Address - Street 1:1137 2ND ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5068
Practice Address - Country:US
Practice Address - Phone:310-458-4581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10688103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10688DMedicare PIN