Provider Demographics
NPI:1053863332
Name:NILSSON, MERLE LATHROP
Entity Type:Individual
Prefix:MR
First Name:MERLE
Middle Name:LATHROP
Last Name:NILSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 ROCK HARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6829
Mailing Address - Country:US
Mailing Address - Phone:407-212-2138
Mailing Address - Fax:
Practice Address - Street 1:1115 ROCK HARBOR AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6829
Practice Address - Country:US
Practice Address - Phone:407-212-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician