Provider Demographics
NPI:1821206186
Name:ERICKSON, PEGGY ELAINE (LMT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ELAINE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ELAINE
Other - Last Name:BROACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:314 E 4TH
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926
Mailing Address - Country:US
Mailing Address - Phone:509-925-4394
Mailing Address - Fax:
Practice Address - Street 1:314 E 4TH
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926
Practice Address - Country:US
Practice Address - Phone:509-925-4394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013808225700000X
WA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0154493OtherSTATE L & I