Provider Demographics
NPI:1396886743
Name:NELSON, VICKI ANN (MA,LLP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 WELLESLEY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-6517
Mailing Address - Country:US
Mailing Address - Phone:586-465-2628
Mailing Address - Fax:
Practice Address - Street 1:46360 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-2800
Practice Address - Country:US
Practice Address - Phone:586-948-0224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007186103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist