Individual
DR. CASEY NELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
1515 MAGNAVOX WAY, FORT WAYNE, IN 46804-1533
(260) 408-1085
Mailing address
1515 MAGNAVOX WAY, FORT WAYNE, IN 46804-1533
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
20041856A
IN
103TM1800X
Intellectual & Developmental Disabilities Psychologist
20041856A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200500290
—
IN
01
—
200501870
MEDICAID WAVIER
IN
Enumeration date
04/23/2007
Last updated
12/12/2008
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