Provider Demographics
NPI:1205253556
Name:NELSON, GREGORY G
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2236
Mailing Address - Country:US
Mailing Address - Phone:920-915-3886
Mailing Address - Fax:
Practice Address - Street 1:607 W 7TH ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5923
Practice Address - Country:US
Practice Address - Phone:920-739-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15767-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)