Provider Demographics
NPI:1972132488
Name:NELSON, CHALICE (LPC)
Entity Type:Individual
Prefix:
First Name:CHALICE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 ASTOR AVE SW APT 1310
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-4867
Mailing Address - Country:US
Mailing Address - Phone:585-694-7413
Mailing Address - Fax:
Practice Address - Street 1:1150 ASTOR AVE SW APT 1310
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-4867
Practice Address - Country:US
Practice Address - Phone:585-694-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health