Provider Demographics
NPI:1316990138
Name:NELSON, SARAH ELIZABETH (OT)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:ELIZABETH
Last Name:NELSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-5116
Mailing Address - Country:US
Mailing Address - Phone:618-241-8595
Mailing Address - Fax:618-241-8759
Practice Address - Street 1:302 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5116
Practice Address - Country:US
Practice Address - Phone:618-241-8595
Practice Address - Fax:618-241-8759
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003194225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18375Medicare PIN