Provider Demographics
NPI:1710425657
Name:DAVIS, ERICA (DPT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:DIEKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1406 6TH AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1901
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7115
Practice Address - Street 1:1406 6TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-656-7115
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41-0695596OtherST. CLOUD HOSPITAL ID#