Provider Demographics
NPI:1790800373
Name:ERICKSON, CARRIE KAY (ATC)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:KAY
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:KAY
Other - Last Name:LEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:5003 CROGANS WAY RD
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-8616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5003 CROGANS WAY RD
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-8616
Practice Address - Country:US
Practice Address - Phone:402-320-8796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00465OtherIA ATH. TRAINING LICENSE
080202275OtherBOC CERTIFICATION