Provider Demographics
NPI:1356632020
Name:NELSON, REINA
Entity Type:Individual
Prefix:
First Name:REINA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 RAINBOW DR # 11351
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77399-2013
Mailing Address - Country:US
Mailing Address - Phone:210-386-7330
Mailing Address - Fax:
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10687235Z00000X
WI100770235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist