Provider Demographics
NPI:1891943437
Name:NELSON, PEGGY LOUANN (OT)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LOUANN
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 1:414 WINNEBAGO AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1230
Mailing Address - Country:US
Mailing Address - Phone:608-742-1485
Mailing Address - Fax:
Practice Address - Street 1:414 WINNEBAGO AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1230
Practice Address - Country:US
Practice Address - Phone:608-742-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1992-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40716900Medicaid