Provider Demographics
NPI:1083807754
Name:ERICKSON, SUSANA MONCADA (LMP)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:MONCADA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:SUSANA
Other - Middle Name:
Other - Last Name:MONCADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16500 SE 15TH ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9665
Mailing Address - Country:US
Mailing Address - Phone:360-718-7944
Mailing Address - Fax:360-718-7931
Practice Address - Street 1:16500 SE 15TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9665
Practice Address - Country:US
Practice Address - Phone:360-718-7944
Practice Address - Fax:360-718-7931
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00023755OtherMASSAGE THERPY