Provider Demographics
NPI:1003112400
Name:ERICKSON, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 21 3/4 ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-3400
Mailing Address - Country:US
Mailing Address - Phone:715-416-1909
Mailing Address - Fax:
Practice Address - Street 1:1801 W KNAPP ST STE 1
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1381
Practice Address - Country:US
Practice Address - Phone:715-416-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1190-019225200000X
WYPTA-0684225200000X
WI13123-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400241091Medicare PIN