Provider Demographics
NPI:1144457326
Name:NELSON, MICHAEL N (PHD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:N
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 WEST CONGRESS PARKWAY
Mailing Address - Street 2:1223 KELLOGG BUILDING
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-942-6656
Mailing Address - Fax:312-942-8592
Practice Address - Street 1:1653 WEST CONGRESS PARKWAY
Practice Address - Street 2:1228 KELLOGG
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-6656
Practice Address - Fax:312-942-8592
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.003181103T00000X, 103TC2200X, 103TM1800X
IL071-003181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities