Provider Demographics
NPI:1598497851
Name:WILSON, ERRICKA D (LMT)
Entity Type:Individual
Prefix:
First Name:ERRICKA
Middle Name:D
Last Name:WILSON
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:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-0006
Mailing Address - Country:US
Mailing Address - Phone:719-407-0681
Mailing Address - Fax:
Practice Address - Street 1:982 DAFFODIL ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4148
Practice Address - Country:US
Practice Address - Phone:719-407-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0025000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist