Provider Demographics
NPI:1750079091
Name:NELSON, STEPHANIE ALEXANDRIA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXANDRIA
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 1:1860 SPRINGVALE RD
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9788
Mailing Address - Country:US
Mailing Address - Phone:803-421-9112
Mailing Address - Fax:
Practice Address - Street 1:1860 SPRINGVALE RD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9788
Practice Address - Country:US
Practice Address - Phone:803-421-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician