Provider Demographics
NPI:1801854377
Name:ERICKSON, LYNN ANNETTE (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ANNETTE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:KETTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0709
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0709
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
880S4EROtherBCBS MINNESOTA
6404867OtherMEDICA
HP18522OtherHEALTHPARTNERS