Provider Demographics
NPI:1033686795
Name:NELSON, IVAN DAVID (CPC)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:DAVID
Last Name:NELSON
Suffix:
Gender:M
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3096
Mailing Address - Country:US
Mailing Address - Phone:360-423-2806
Mailing Address - Fax:360-423-5128
Practice Address - Street 1:748 14TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-200-5419
Practice Address - Fax:360-200-6736
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
WA60775408101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2155913Medicaid