Provider Demographics
NPI:1184121303
Name:NELSON, PATINA E (LCDCIII)
Entity type:Individual
Prefix:
First Name:PATINA
Middle Name:E
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MARTIN LUTHER KING DR W
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220
Mailing Address - Country:US
Mailing Address - Phone:513-475-5800
Mailing Address - Fax:
Practice Address - Street 1:311 MARTIN LUTHER KING DR W
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220
Practice Address - Country:US
Practice Address - Phone:513-475-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161433101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI161433OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD