Provider Demographics
NPI:1265191159
Name:NELSON, SAMANTHA NICOLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-5474
Mailing Address - Country:US
Mailing Address - Phone:517-394-7867
Mailing Address - Fax:517-394-7869
Practice Address - Street 1:4920 SOUTH CEDAR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-394-7867
Practice Address - Fax:517-394-7869
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical