Provider Demographics
NPI:1679009583
Name:ERICKSON, CYNTHIA (RD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44223 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44223 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1925
Practice Address - Country:US
Practice Address - Phone:734-552-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI806047133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered