Provider Demographics
NPI:1760871412
Name:ERICKSON, LORI (MPT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 43RD ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-1874
Mailing Address - Country:US
Mailing Address - Phone:505-795-0607
Mailing Address - Fax:
Practice Address - Street 1:4717 QUEMAZON
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-6600
Practice Address - Country:US
Practice Address - Phone:505-662-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist