Provider Demographics
NPI:1740653344
Name:NELSON, BRIAN J
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-637-5668
Mailing Address - Fax:262-637-5009
Practice Address - Street 1:1092 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1362
Practice Address - Country:US
Practice Address - Phone:262-757-0200
Practice Address - Fax:262-757-0201
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1383237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist