Basic Information
| Provider Information | |||||||||
| NPI: | 1174594568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | ERIK | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016092265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083634664 | ||||||||
| FaxNumber: | 5087527245 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016092265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083634664 | ||||||||
| FaxNumber: | 5087527245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 07/27/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6292 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0522147 | 05 | MA | MEDICAID |