Provider Demographics
NPI:1982431896
Name:NELSON, TESSA RAE (CSW)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:RAE
Last Name:NELSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 OLD MAIN
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322
Mailing Address - Country:US
Mailing Address - Phone:435-797-4200
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6405 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6405
Practice Address - Country:US
Practice Address - Phone:435-797-4200
Practice Address - Fax:844-308-5865
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13455287-3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health