Provider Demographics
NPI:1235249418
Name:VAZQUEZ, NELSON (OT)
Entity Type:Individual
Prefix:MR
First Name:NELSON
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:10626 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4526
Practice Address - Country:US
Practice Address - Phone:864-482-0085
Practice Address - Fax:864-482-0072
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1031225000000X, 225XH1200X
SC3413225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889777800Medicaid
FLZ7576YMedicare ID - Type Unspecified
FLZ7576ZMedicare ID - Type Unspecified