Provider Demographics
NPI:1164543559
Name:ERICKSON, CONSTANCE L (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 TRANQUIL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-8047
Mailing Address - Country:US
Mailing Address - Phone:276-322-3773
Mailing Address - Fax:
Practice Address - Street 1:WESTWOOD OFFICE PARK
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605
Practice Address - Country:US
Practice Address - Phone:276-322-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003789235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist