Provider Demographics
NPI:1710255419
Name:NELSON, THEODORA PRICE (NYS LICENSE)
Entity Type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:PRICE
Last Name:NELSON
Suffix:
Gender:F
Credentials:NYS LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8685 ERIE RD
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006-9620
Mailing Address - Country:US
Mailing Address - Phone:716-549-4454
Mailing Address - Fax:716-549-0217
Practice Address - Street 1:100 N ERIE ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-9755
Practice Address - Country:US
Practice Address - Phone:716-753-5843
Practice Address - Fax:716-753-5850
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist