Basic Information
| Provider Information | |||||||||
| NPI: | 1902888555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSED, LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON EGGERS | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSED, LP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 25TH AVE S | ||||||||
| Address2: | STE 109 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563014841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202550343 | ||||||||
| FaxNumber: | 3206540318 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 25TH AVE S | ||||||||
| Address2: | STE 109 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563014841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202550343 | ||||||||
| FaxNumber: | 3206540318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP3099 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 110216 | 01 | UCARE | OTHER | 411768605 | 01 | CERIDIAN | OTHER | 785325400 | 05 | MN | MEDICAID | 6262609 | 01 | UBH MEDICA SELECT CARE | OTHER | 82D17NE | 01 | BCBS COMP CARE | OTHER | 2315034 | 01 | AMERICAS PPO | OTHER | 766591015131 | 01 | PREFERRED ONE | OTHER | 187408 | 01 | MAYO MANAGEMENT | OTHER | 337324 | 01 | VALUE OPTIONS | OTHER |