1063732527 NPI number — COLLEEN L NIELSEN OTR/L

Table of content: COLLEEN L NIELSEN OTR/L (NPI 1063732527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063732527 NPI number — COLLEEN L NIELSEN OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
COLLEEN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MITCHELL
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063732527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 W FRONTAGE RD
Provider Second Line Business Mailing Address:
SUITE 2415
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60093-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-259-4094
Provider Business Mailing Address Fax Number:
847-386-5191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 N BLUFF BLVD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52732-7146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-242-4422
Provider Business Practice Location Address Fax Number:
563-243-8329
Provider Enumeration Date:
06/08/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  00544 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 056002724 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)