Provider Demographics
NPI:1760779441
Name:NELSON, HEATHER LISA (COTA/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LISA
Last Name:NELSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 CAMDEN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:ME
Mailing Address - Zip Code:04864-4124
Mailing Address - Country:US
Mailing Address - Phone:207-273-8100
Mailing Address - Fax:207-273-8103
Practice Address - Street 1:3208 CAMDEN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:ME
Practice Address - Zip Code:04864-4124
Practice Address - Country:US
Practice Address - Phone:207-273-8100
Practice Address - Fax:207-273-8103
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA2589224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant