Provider Demographics
NPI:1649469461
Name:NELSON, TRACY RADIG (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RADIG
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1914
Mailing Address - Country:US
Mailing Address - Phone:701-476-7200
Mailing Address - Fax:701-476-7261
Practice Address - Street 1:3911 20TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4705
Practice Address - Country:US
Practice Address - Phone:701-271-3232
Practice Address - Fax:701-235-7359
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND33091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical