Provider Demographics
NPI:1477682904
Name:NELSON, CRAIG EDWARD (OTR)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:EDWARD
Last Name:NELSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 PROMONTORY PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2075
Mailing Address - Country:US
Mailing Address - Phone:804-304-8453
Mailing Address - Fax:
Practice Address - Street 1:7TH AND ALBEMARLE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-0030
Practice Address - Country:US
Practice Address - Phone:804-524-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000190225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119000190OtherLICENSE