Provider Demographics
NPI:1548718869
Name:PORTER-NELSON, ELEANOR (MSW)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:PORTER-NELSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ELEANOR
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2136 FORD PKWY # 5294
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2850
Mailing Address - Country:US
Mailing Address - Phone:612-467-9924
Mailing Address - Fax:612-234-4261
Practice Address - Street 1:2136 FORD PKWY # 5294
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2850
Practice Address - Country:US
Practice Address - Phone:612-467-9924
Practice Address - Fax:612-234-4261
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN266631041C0700X
IL149.0185241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1548718869Medicaid