Provider Demographics
NPI:1013920560
Name:NILSSON, INGRID SUSAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:SUSAN
Last Name:NILSSON
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 1:2105 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-3144
Mailing Address - Country:US
Mailing Address - Phone:270-575-1863
Mailing Address - Fax:
Practice Address - Street 1:2299 METROPOLIS ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1320
Practice Address - Country:US
Practice Address - Phone:618-524-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1879225X00000X
IN31001703A225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist