Provider Demographics
NPI:1649892548
Name:NELSON-GATES, ANGIE L (LMFT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:L
Last Name:NELSON-GATES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CENTENNIAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504
Mailing Address - Country:US
Mailing Address - Phone:612-251-7551
Mailing Address - Fax:
Practice Address - Street 1:25 CENTENNIAL AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5921
Practice Address - Country:US
Practice Address - Phone:612-251-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1685106H00000X
MI4101006919106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty