Provider Demographics
NPI:1730271404
Name:NELSON, SUSAN ALICE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ALICE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:ALICE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:VANOUDHEUSDEN,
Mailing Address - Street 1:502 W HARRIE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1209
Mailing Address - Country:US
Mailing Address - Phone:906-293-9233
Mailing Address - Fax:
Practice Address - Street 1:W16496 MCCONNEL RD
Practice Address - Street 2:
Practice Address - City:CURTIS
Practice Address - State:MI
Practice Address - Zip Code:49820-9650
Practice Address - Country:US
Practice Address - Phone:701-630-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085662104100000X, 1041C0700X
ND45111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730271404Medicaid