Provider Demographics
NPI:1396045076
Name:NELSON, ELIZABETH (MA SLPCCC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA SLPCCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 EAGLE LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DESERT
Mailing Address - State:ME
Mailing Address - Zip Code:04660
Mailing Address - Country:US
Mailing Address - Phone:207-288-5011
Mailing Address - Fax:
Practice Address - Street 1:1081 EAGLE LAKE RD
Practice Address - Street 2:
Practice Address - City:BAR HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04609-7331
Practice Address - Country:US
Practice Address - Phone:207-288-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1064235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist