Provider Demographics
NPI:1881667186
Name:NIELSEN, TERI LEE (LPC, CMHC)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:LEE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:LPC, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 W GRAND CANYON DR
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-6024
Mailing Address - Country:US
Mailing Address - Phone:425-891-1896
Mailing Address - Fax:435-644-8577
Practice Address - Street 1:1080 W GRAND CANYON DR
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-6024
Practice Address - Country:US
Practice Address - Phone:425-891-1896
Practice Address - Fax:435-644-8577
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-16973101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANI5213OtherRIDER NUMBER W. REGENCE
WA601 422 415OtherUBI