Provider Demographics
NPI:1063793032
Name:NELSON, JUSTINE LYN (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:LYN
Last Name:NELSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 E MARTIN LUTHER KING JR DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-4864
Mailing Address - Country:US
Mailing Address - Phone:727-207-7271
Mailing Address - Fax:
Practice Address - Street 1:905 E MARTIN LUTHER KING JR DR
Practice Address - Street 2:SUITE 400
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4864
Practice Address - Country:US
Practice Address - Phone:727-207-7271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 11077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist