Provider Demographics
NPI:1891173357
Name:NELSON, MICHELLE ELIZABETH (LMFT#114300)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMFT#114300
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ELIZABETH
Other - Last Name:ODEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTI#94133
Mailing Address - Street 1:1040 W. KETTLEMEN LN. PMB #326
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-986-7149
Mailing Address - Fax:
Practice Address - Street 1:2081 HOLT DR.
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-986-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAIMF94133106H00000X, 390200000X
CA114300106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program