Provider Demographics
NPI:1932975927
Name:NELSON, CAROLYN DENISE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DENISE
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 1:30555 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5310
Mailing Address - Country:US
Mailing Address - Phone:734-629-5000
Mailing Address - Fax:734-722-8397
Practice Address - Street 1:30555 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5310
Practice Address - Country:US
Practice Address - Phone:734-629-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health