Provider Demographics
NPI:1225298839
Name:NEILSON, AUTUMN BROOKE (LMT)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:BROOKE
Last Name:NEILSON
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 1:173 N ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2914
Mailing Address - Country:US
Mailing Address - Phone:321-783-2029
Mailing Address - Fax:
Practice Address - Street 1:173 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2914
Practice Address - Country:US
Practice Address - Phone:321-783-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist