Provider Demographics
NPI:1811572605
Name:NELSON, MANDY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 S WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-9237
Mailing Address - Country:US
Mailing Address - Phone:509-998-0690
Mailing Address - Fax:
Practice Address - Street 1:917 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-762-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist