Provider Demographics
NPI:1487138061
Name:NELSON, BRAD JOSEPH (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:JOSEPH
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 WASHINGTON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1600
Mailing Address - Country:US
Mailing Address - Phone:208-847-4464
Mailing Address - Fax:208-847-3093
Practice Address - Street 1:455 WASHIGTON ST
Practice Address - Street 2:STE 2
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1600
Practice Address - Country:US
Practice Address - Phone:208-847-4464
Practice Address - Fax:208-847-3093
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38058104100000X
ID38058101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805405600Medicaid