Basic Information
Provider Information
NPI: 1003156761
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NELSON
FirstName: BLYTHE
MiddleName: ELLEN
NamePrefix:  
NameSuffix:  
Credential: LGSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 653 DAYTON AVE
Address2:  
City: SAINT PAUL
State: MN
PostalCode: 551046631
CountryCode: US
TelephoneNumber: 6513302052
FaxNumber: 6513304077
Practice Location
Address1: 653 DAYTON AVE
Address2:  
City: SAINT PAUL
State: MN
PostalCode: 551046631
CountryCode: US
TelephoneNumber: 6513302052
FaxNumber: 6513304077
Other Information
ProviderEnumerationDate: 02/18/2013
LastUpdateDate: 02/18/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X20794MNY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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