Provider Demographics
NPI:1083133433
Name:ERICKSON, MACY JO (MS, SLP-CF)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:JO
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MS, SLP-CF
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:JO
Other - Last Name:WILDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, SLP-CF
Mailing Address - Street 1:520 N 28TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4101
Mailing Address - Country:US
Mailing Address - Phone:715-845-4900
Mailing Address - Fax:715-845-4970
Practice Address - Street 1:520 N 28TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4101
Practice Address - Country:US
Practice Address - Phone:715-845-4900
Practice Address - Fax:715-845-4970
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4543-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist