Provider Demographics
NPI:1942494968
Name:NELSON, RICHARD GARY
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GARY
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NELSON
Other - Middle Name:
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:963 WOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-8731
Mailing Address - Country:US
Mailing Address - Phone:720-329-3361
Mailing Address - Fax:
Practice Address - Street 1:963 WOLF CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-8731
Practice Address - Country:US
Practice Address - Phone:720-329-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health