Provider Demographics
NPI:1134355191
Name:NELSON, MARTY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CAPITOL AVE, HATHAWAY BLDG
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82002
Mailing Address - Country:US
Mailing Address - Phone:307-777-6203
Mailing Address - Fax:307-777-3693
Practice Address - Street 1:2300 CAPITOL AVE, HATHAWAY BLDG
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82002
Practice Address - Country:US
Practice Address - Phone:307-777-7150
Practice Address - Fax:307-777-3693
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional