Provider Demographics
NPI:1548311327
Name:NELSON, CHRISTIE (PHD)
Entity type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
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:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:130 E WALNUT ST
Practice Address - Street 2:SUITE 706
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4239
Practice Address - Country:US
Practice Address - Phone:920-437-8256
Practice Address - Fax:920-437-1188
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39151200Medicaid
WI39151200Medicaid