Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 300740 | MN |
NPI | 1003197567 |
---|---|
Provider Name | Dennis Nelson |
First Address | Prior Lake, MN 55372-9077 |
Second Address | Prior Lake, MN 55372-9077 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2011 |
Last Update Date | 29/08/2011 |