Provider Demographics
NPI:1639438377
Name:NELSON, MARY E (MS, LAC, LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2340
Mailing Address - Country:US
Mailing Address - Phone:631-680-2902
Mailing Address - Fax:
Practice Address - Street 1:152 ISLIP AVE
Practice Address - Street 2:SUITE 23
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3225
Practice Address - Country:US
Practice Address - Phone:631-277-6767
Practice Address - Fax:631-277-4311
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25-004803171100000X
NY013931225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist