Provider Demographics
NPI:1881464451
Name:NELSON, DEBORAH MARIE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:MARIE
Other - Last Name:IDLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1338 COMMERCE AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2428 W REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4554
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator