Provider Demographics
NPI:1508581570
Name:ERICKSON, GENNETTE MARIE
Entity Type:Individual
Prefix:
First Name:GENNETTE
Middle Name:MARIE
Last Name:ERICKSON
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 1:190 TALISMAN DR UNIT C3
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9171
Mailing Address - Country:US
Mailing Address - Phone:970-731-4554
Mailing Address - Fax:970-731-1868
Practice Address - Street 1:190 TALISMAN DR UNIT C3
Practice Address - Street 2:
Practice Address - City:PAGOSA SPGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-731-4554
Practice Address - Fax:970-731-1868
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHAD475237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist