Provider Demographics
NPI:1831391085
Name:NELSON, BRENDA X
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:NELSON
Suffix:X
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 1:1600 METROPOLITAN AVE
Mailing Address - Street 2:APT. 3A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6976
Mailing Address - Country:US
Mailing Address - Phone:917-657-5795
Mailing Address - Fax:
Practice Address - Street 1:2534 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3702
Practice Address - Country:US
Practice Address - Phone:718-777-5243
Practice Address - Fax:718-777-5250
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070929104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker