Provider Demographics
NPI:1184235053
Name:NELSON, TEAL (LAC)
Entity type:Individual
Prefix:
First Name:TEAL
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 19TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6634
Mailing Address - Country:US
Mailing Address - Phone:701-837-4989
Mailing Address - Fax:701-837-9660
Practice Address - Street 1:515 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6634
Practice Address - Country:US
Practice Address - Phone:701-837-4989
Practice Address - Fax:701-837-9660
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1796101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)