Provider Demographics
NPI:1093989261
Name:ERNEST, ERIC WILLIAM (MS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
Last Name:ERNEST
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14425 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4456
Mailing Address - Country:US
Mailing Address - Phone:763-607-2091
Mailing Address - Fax:
Practice Address - Street 1:14425 8TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4456
Practice Address - Country:US
Practice Address - Phone:763-607-2091
Practice Address - Fax:763-550-1633
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1181-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist