Provider Demographics
NPI:1871771592
Name:NELSON, SHIRLEY B
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:B
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 1:23119 COTTONWOOD AVE
Mailing Address - Street 2:BUILDING A, SUITE 110
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-413-5678
Mailing Address - Fax:951-413-5660
Practice Address - Street 1:23119 COTTONWOOD AVE
Practice Address - Street 2:BUILDING A, SUITE 110
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9661
Practice Address - Country:US
Practice Address - Phone:951-413-5678
Practice Address - Fax:951-413-5660
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health