Provider Demographics
NPI:1386819043
Name:NELSON, MARY EILEEN (OTR)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:EILEEN
Last Name:NELSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-3006
Mailing Address - Country:US
Mailing Address - Phone:815-398-0960
Mailing Address - Fax:815-398-9466
Practice Address - Street 1:6080 ELAINE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3006
Practice Address - Country:US
Practice Address - Phone:815-398-0960
Practice Address - Fax:815-398-9466
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist