Provider Demographics
NPI:1528379724
Name:ERICKSON, ANN GOGENOLA (MS, CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:GOGENOLA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MS, CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 GARA PL
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5720
Mailing Address - Country:US
Mailing Address - Phone:503-440-0802
Mailing Address - Fax:
Practice Address - Street 1:930 GARA PL
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-5720
Practice Address - Country:US
Practice Address - Phone:503-440-0802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR013096OtherOREGON BOARD OF EXAMINERS
01024475OtherASHA CERTIFICATION