Provider Demographics
NPI:1043403199
Name:NELSON, MARCIA ANN (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:ANN
Other - Last Name:KILPONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 JUDY LEE ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443
Mailing Address - Country:US
Mailing Address - Phone:307-864-3376
Mailing Address - Fax:
Practice Address - Street 1:1025 SHOSHONI
Practice Address - Street 2:CHILDRENS RESOURCE CENTER
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443
Practice Address - Country:US
Practice Address - Phone:307-864-9227
Practice Address - Fax:307-864-2296
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR027225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1770688871Medicaid