Provider Demographics
NPI:1639858681
Name:ERICKSON, ELISE (OTR)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 COLBY ST APT 236
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2056
Mailing Address - Country:US
Mailing Address - Phone:952-250-4965
Mailing Address - Fax:
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist