Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TB0200X | Cognitive & Behavioral Psychologist | 6301014498 | MI |
Y | 103G00000X | Clinical Psychologist | 6301014498 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301014498 | MI |
NPI | 1154511350 |
---|---|
Provider Name | Dr. Clayton Beau Nelson |
First Address | Ann Arbor, MI 48105-2303 |
Second Address | Ann Arbor, MI 48105-2303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2007 |
Last Update Date | 20/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100117700A | (05) | KS |