Provider Demographics
NPI:1578708418
Name:ERICKSON, SUSAN RENE' (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENE'
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MAIN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6414
Mailing Address - Country:US
Mailing Address - Phone:406-752-3881
Mailing Address - Fax:
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:STE 202
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6414
Practice Address - Country:US
Practice Address - Phone:406-752-3881
Practice Address - Fax:406-755-5120
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ085900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist