Provider Demographics
NPI:1932256328
Name:NELSON, CARRIE JUANITA (PHD, LICSW-PIP, MFT)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:JUANITA
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHD, LICSW-PIP, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4252 CARMICHAEL RD STE 107-108
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2804
Mailing Address - Country:US
Mailing Address - Phone:334-356-4960
Mailing Address - Fax:334-356-4961
Practice Address - Street 1:4252 CARMICHAEL RD STE 107-108
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2804
Practice Address - Country:US
Practice Address - Phone:334-356-4960
Practice Address - Fax:334-356-4961
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0759-1646-C1041C0700X
AL1646C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1932256328Medicaid