Provider Demographics
NPI:1548456569
Name:NELSON, GWEN ALISON (MS, LCSW)
Entity type:Individual
Prefix:MS
First Name:GWEN
Middle Name:ALISON
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:MS
Other - First Name:GWEN
Other - Middle Name:ALISON
Other - Last Name:GAYHART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LCSW
Mailing Address - Street 1:484 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1417
Mailing Address - Country:US
Mailing Address - Phone:262-332-0131
Mailing Address - Fax:
Practice Address - Street 1:484 N PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1417
Practice Address - Country:US
Practice Address - Phone:262-332-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical