Provider Demographics
NPI:1063865590
Name:PERLMAN - HENSEN, ERICA (OD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:PERLMAN - HENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 TOWN CENTER AVE, UNIT #A6
Mailing Address - Street 2:P.O. BOX # 160700
Mailing Address - City:BIG SKY
Mailing Address - State:MT
Mailing Address - Zip Code:59716-0700
Mailing Address - Country:US
Mailing Address - Phone:406-414-0006
Mailing Address - Fax:
Practice Address - Street 1:99 TOWN CENTER AVE, UNIT #A6
Practice Address - Street 2:
Practice Address - City:BIG SKY
Practice Address - State:MT
Practice Address - Zip Code:59716-0700
Practice Address - Country:US
Practice Address - Phone:406-414-0006
Practice Address - Fax:406-414-0004
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33544152W00000X
MT3390152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1063865590Medicaid