Provider Demographics
NPI:1679749394
Name:ERICSON, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ERICSON
Suffix:
Gender:F
Credentials:
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 155
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:OH
Mailing Address - Zip Code:44455-0155
Mailing Address - Country:US
Mailing Address - Phone:330-301-4595
Mailing Address - Fax:
Practice Address - Street 1:6102 LOW RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9347
Practice Address - Country:US
Practice Address - Phone:330-301-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor