Provider Demographics
NPI:1750905881
Name:NELSON, DOUGLAS (LMT, BCTMB)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7722
Mailing Address - Country:US
Mailing Address - Phone:217-351-1011
Mailing Address - Fax:
Practice Address - Street 1:407 E WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7722
Practice Address - Country:US
Practice Address - Phone:217-351-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227001826225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist