Provider Demographics
NPI:1831372382
Name:WALTHRUST, NELLIE TAYLOR (CASAC)
Entity type:Individual
Prefix:MRS
First Name:NELLIE
Middle Name:TAYLOR
Last Name:WALTHRUST
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 OLD WESTBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2215
Mailing Address - Country:US
Mailing Address - Phone:516-626-1971
Mailing Address - Fax:516-626-8043
Practice Address - Street 1:999 BRUSH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1704
Practice Address - Country:US
Practice Address - Phone:516-997-2926
Practice Address - Fax:516-997-4721
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8328101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)