Provider Demographics
NPI:1881923316
Name:NIELSON, LANCE REECE (PH D)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:REECE
Last Name:NIELSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 UNIVERSITY CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2706
Mailing Address - Country:US
Mailing Address - Phone:540-961-8300
Mailing Address - Fax:540-961-8469
Practice Address - Street 1:700 UNIVERSITY CITY BLVD
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2706
Practice Address - Country:US
Practice Address - Phone:540-961-8300
Practice Address - Fax:540-961-8469
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO3501Medicaid