Provider Demographics
NPI:1083807994
Name:NELSON, TERESA LUCILLE (LMT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LUCILLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROOK MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-3941
Mailing Address - Country:US
Mailing Address - Phone:850-982-0775
Mailing Address - Fax:850-476-6041
Practice Address - Street 1:760 BROOK MEADOW LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-3941
Practice Address - Country:US
Practice Address - Phone:850-982-0775
Practice Address - Fax:850-476-6041
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 39235225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist