Provider Demographics
NPI:1063586634
Name:NIELSON, ERIC MATHEW (OTRL)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MATHEW
Last Name:NIELSON
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6246 SO REDWOOD RD
Mailing Address - Street 2:AVALON BENNION CARE CENTER
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-955-0690
Mailing Address - Fax:801-955-2540
Practice Address - Street 1:6246 SO REDWOOD RD
Practice Address - Street 2:AVALON BENNION CARE CENTER
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-955-0690
Practice Address - Fax:801-955-2540
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3481244201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4617Medicaid