Provider Demographics
NPI:1134268626
Name:NELSON, SCOTT BRUCE (PHD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRUCE
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3307
Mailing Address - Country:US
Mailing Address - Phone:480-472-1039
Mailing Address - Fax:480-472-1110
Practice Address - Street 1:855 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3401
Practice Address - Country:US
Practice Address - Phone:480-472-1039
Practice Address - Fax:480-472-1110
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1632103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788391Medicaid