Provider Demographics
NPI:1366598542
Name:NIELSEN, MARY JANE (MSSA, LISW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MSSA, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9138 PAYNE FARM LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-9388
Mailing Address - Country:US
Mailing Address - Phone:937-885-3782
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-1921
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:937-534-1347
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI4458104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW14064Medicare UPIN
OHSW14064Medicare ID - Type Unspecified