Provider Demographics
NPI:1881914786
Name:NELSON, CAROL LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8767 SEMINOLE TRL STE 201C
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3494
Mailing Address - Country:US
Mailing Address - Phone:239-405-1249
Mailing Address - Fax:
Practice Address - Street 1:8767 SEMINOLE TRL STE 201C
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968-3494
Practice Address - Country:US
Practice Address - Phone:239-405-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW98951041C0700X
VA09040099181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1881914786Medicaid