Provider Demographics
NPI:1396381554
Name:NELSON, JUSTIN (OTD, OTR/L, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:OTD, OTR/L, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 S DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 W MOUND RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1263
Practice Address - Country:US
Practice Address - Phone:217-615-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist