Provider Demographics
NPI:1205097870
Name:MICHAEL JAN NELSON PHD
Entity type:Organization
Organization Name:MICHAEL JAN NELSON PHD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIGLER EDMUNDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:715-712-1370
Mailing Address - Street 1:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-1535
Mailing Address - Country:US
Mailing Address - Phone:715-424-3400
Mailing Address - Fax:715-424-3441
Practice Address - Street 1:420 1ST AVE S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495
Practice Address - Country:US
Practice Address - Phone:715-424-3400
Practice Address - Fax:715-424-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X
WI1298251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty