Provider Demographics
NPI:1972244887
Name:NELSON, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
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 1:16839 E BYGROVE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1108
Mailing Address - Country:US
Mailing Address - Phone:818-876-2615
Mailing Address - Fax:
Practice Address - Street 1:1063 MCGAW AVE STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5554
Practice Address - Country:US
Practice Address - Phone:657-242-2079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst