Provider Demographics
NPI:1649678053
Name:NELSEN, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:NELSEN
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 1:301 S ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2070
Mailing Address - Country:US
Mailing Address - Phone:518-489-7777
Mailing Address - Fax:
Practice Address - Street 1:301 S ALLEN ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2070
Practice Address - Country:US
Practice Address - Phone:518-489-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20836101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)