Provider Demographics
NPI:1023120086
Name:NELSON, KEITH (LCSW)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 GOLDCREST AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2006
Mailing Address - Country:US
Mailing Address - Phone:503-362-5083
Mailing Address - Fax:
Practice Address - Street 1:150 KINGWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4030
Practice Address - Country:US
Practice Address - Phone:503-588-5816
Practice Address - Fax:503-588-5803
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL38021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134456Medicare PIN