Provider Demographics
NPI:1275524266
Name:ERICKSON, TATE STEPHEN (ATC)
Entity Type:Individual
Prefix:MR
First Name:TATE
Middle Name:STEPHEN
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 WEST ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-2809
Mailing Address - Country:US
Mailing Address - Phone:603-903-0047
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1715
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer