Provider Demographics
NPI:1609951946
Name:NELSON, BRUCE ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 MCANDREWS RD W STE 219
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4445
Mailing Address - Country:US
Mailing Address - Phone:952-212-7508
Mailing Address - Fax:952-234-8833
Practice Address - Street 1:1500 MCANDREWS RD W STE 219
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4445
Practice Address - Country:US
Practice Address - Phone:952-212-7508
Practice Address - Fax:952-892-8451
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5060583-00Medicaid
MN680001842Medicare ID - Type UnspecifiedMEDICARE ID NUMBER