Provider Demographics
NPI:1639307911
Name:PETERSON, ERIKA L
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIKA
Other - Middle Name:L
Other - Last Name:WICKARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:4897 STATE ROUTE 209
Practice Address - Street 2:
Practice Address - City:ELIZABETHVILLE
Practice Address - State:PA
Practice Address - Zip Code:17023-8455
Practice Address - Country:US
Practice Address - Phone:717-362-8810
Practice Address - Fax:717-362-3340
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADAPT002409225100000X
PAPT019999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026217670001Medicaid