Provider Demographics
NPI:1568103141
Name:ERICKSON, TERESA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N GRIFFIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1540
Mailing Address - Country:US
Mailing Address - Phone:970-370-3386
Mailing Address - Fax:
Practice Address - Street 1:104 N GRIFFIN ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1540
Practice Address - Country:US
Practice Address - Phone:970-370-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003977225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant