Healthcare Provider Details

I. General information

NPI: 1740006394
Provider Name (Legal Business Name): NELSON OTIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PAUL X TIVNAN DR
WEST BOYLSTON MA
01583-2126
US

IV. Provider business mailing address

42 MARLBORO ST
WORCESTER MA
01604-1739
US

V. Phone/Fax

Practice location:
  • Phone: 267-897-2661
  • Fax:
Mailing address:
  • Phone: 267-897-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: