Provider Demographics
NPI:1134519572
Name:NELSON, TRUDY (LAC, CCS)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LAC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 BORDELON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351
Mailing Address - Country:US
Mailing Address - Phone:318-279-2757
Mailing Address - Fax:
Practice Address - Street 1:10631 HIGHWAY 71 S
Practice Address - Street 2:EDGEFIELD RECOVERY CENTER
Practice Address - City:CHENEYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71325
Practice Address - Country:US
Practice Address - Phone:318-279-2757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1410101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)