Provider Demographics
NPI:1942367131
Name:NELSON, MICHAEL KENNETH (MSED, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 BARBER AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-5202
Mailing Address - Country:US
Mailing Address - Phone:401-921-2594
Mailing Address - Fax:
Practice Address - Street 1:56 BARBER AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-5202
Practice Address - Country:US
Practice Address - Phone:401-921-2594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
RIAT001942255A2300X
MA14072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer