Provider Demographics
NPI:1003262544
Name:NIELSON, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NIELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-8337
Mailing Address - Country:US
Mailing Address - Phone:801-636-6452
Mailing Address - Fax:
Practice Address - Street 1:13609 CALIFORNIA STREET, SUITE 200
Practice Address - Street 2:C&A PLAZA,
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5260
Practice Address - Country:US
Practice Address - Phone:402-891-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60642487225XP0019X
TX118756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation