Provider Demographics
NPI:1174971014
Name:NELSON, TREVOR JAMES (LCSW)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:JAMES
Last Name:NELSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2057
Mailing Address - Country:US
Mailing Address - Phone:208-243-9304
Mailing Address - Fax:208-656-5668
Practice Address - Street 1:33 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2057
Practice Address - Country:US
Practice Address - Phone:208-243-9304
Practice Address - Fax:208-656-5668
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-357461041C0700X
IDLCSW-381931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical