Provider Demographics
NPI:1053353904
Name:NELSON, BENJAMIN (MSPT, OCS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12849 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5813
Mailing Address - Country:US
Mailing Address - Phone:503-208-6278
Mailing Address - Fax:503-208-6276
Practice Address - Street 1:4445 SW BARBUR BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4047
Practice Address - Country:US
Practice Address - Phone:503-235-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009802225100000X
OR38332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist