Provider Demographics
NPI:1255403424
Name:NIELSEN, MELISSA SUSAN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUSAN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9171 FALCON GREENS DR
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 PINGREE RD
Practice Address - Street 2:SUITE119
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1725
Practice Address - Country:US
Practice Address - Phone:847-458-8890
Practice Address - Fax:847-458-8889
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics