Provider Demographics
NPI:1801013313
Name:NELSON, JOHN GORDON (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:GORDON
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1137 2ND ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5011
Mailing Address - Country:US
Mailing Address - Phone:310-394-1138
Mailing Address - Fax:
Practice Address - Street 1:1137 2ND ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5011
Practice Address - Country:US
Practice Address - Phone:310-394-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 9453, LEP 1168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health