Provider Demographics
NPI:1346401460
Name:MANDRICK, ERICA L (AUD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:MANDRICK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:L
Other - Last Name:SODERQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 N. WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-994-2770
Mailing Address - Fax:616-920-6533
Practice Address - Street 1:3100 N. WELLNESS DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-994-2770
Practice Address - Fax:616-920-6533
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X, 237600000X
MI1601000515231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460259Medicare PIN