Provider Demographics
NPI:1871930230
Name:NILSEN, LAURA B (EDS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:B
Last Name:NILSEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2172 BRIGHTON BAY TRL W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7205
Mailing Address - Country:US
Mailing Address - Phone:904-476-5916
Mailing Address - Fax:
Practice Address - Street 1:4745 SUTTON PARK CT
Practice Address - Street 2:SUITE 802
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0250
Practice Address - Country:US
Practice Address - Phone:904-476-5916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS848103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool