Provider Demographics
NPI:1760640379
Name:ERICKSON, THERESA (SLP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 RIDGEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-4601
Mailing Address - Country:US
Mailing Address - Phone:518-732-7442
Mailing Address - Fax:
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3950
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:781-933-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist