Provider Demographics
NPI:1205113875
Name:NELSON, TERRA RENEE (MPT)
Entity type:Individual
Prefix:MS
First Name:TERRA
Middle Name:RENEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 34TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2109
Mailing Address - Country:US
Mailing Address - Phone:619-955-3459
Mailing Address - Fax:
Practice Address - Street 1:4141 34TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2109
Practice Address - Country:US
Practice Address - Phone:619-955-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29298OtherCALIFORNIA PT LICENSE