Provider Demographics
NPI:1700159563
Name:NELSON, JOHN-MIKE (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN-MIKE
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-4162
Mailing Address - Country:US
Mailing Address - Phone:804-695-8119
Mailing Address - Fax:804-695-8122
Practice Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4162
Practice Address - Country:US
Practice Address - Phone:804-695-8119
Practice Address - Fax:804-695-8122
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497717615Medicaid