Provider Demographics
NPI:1881149094
Name:NELSON, AMANDA DIANN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANN
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:PO BOX 1649
Mailing Address - Street 2:3530 N CTY RD F
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53547-1649
Mailing Address - Country:US
Mailing Address - Phone:608-757-5200
Mailing Address - Fax:
Practice Address - Street 1:113 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3812
Practice Address - Country:US
Practice Address - Phone:608-757-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17733-130101YA0400X
WI2830-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional