Provider Demographics
NPI:1326390527
Name:ERICKSON, SUSAN JANE (MA CCC SP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MA CCC SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2103
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257
Mailing Address - Country:US
Mailing Address - Phone:360-466-3171
Mailing Address - Fax:360-466-3523
Practice Address - Street 1:305 N. 6TH
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:360-466-3171
Practice Address - Fax:360-466-3523
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist