Provider Demographics
NPI:1851724959
Name:NELSON, ROBERT GRAYDON
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GRAYDON
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 RIVERSIDE AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2682
Mailing Address - Country:US
Mailing Address - Phone:310-767-6461
Mailing Address - Fax:
Practice Address - Street 1:1111 RIVERSIDE AVE STE 404
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2682
Practice Address - Country:US
Practice Address - Phone:805-610-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 101YA0400X
CALMFT145789106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)