Provider Demographics
NPI:1093253940
Name:ERICKSON PT ENTERPRISES PLLC
Entity Type:Organization
Organization Name:ERICKSON PT ENTERPRISES PLLC
Other - Org Name:LAKE COUNTRY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENNER-ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-263-1632
Mailing Address - Street 1:1005 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1702
Mailing Address - Country:US
Mailing Address - Phone:208-263-1632
Mailing Address - Fax:208-255-2066
Practice Address - Street 1:1005 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1702
Practice Address - Country:US
Practice Address - Phone:208-263-1632
Practice Address - Fax:208-255-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806604100Medicaid