Provider Demographics
NPI:1922169630
Name:NIELSEN, SANDRA (COTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 MELODI LN
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-9650
Mailing Address - Country:US
Mailing Address - Phone:307-258-3248
Mailing Address - Fax:307-472-2277
Practice Address - Street 1:2521 E 15TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4126
Practice Address - Country:US
Practice Address - Phone:307-473-7144
Practice Address - Fax:307-472-2277
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant