Provider Demographics
NPI:1114057015
Name:NESVIG PADDOCK, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:NESVIG PADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 PONEMAH TRL
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49620-9554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2950 LAFRANIER RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4918
Practice Address - Country:US
Practice Address - Phone:231-947-0506
Practice Address - Fax:231-947-0744
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist