Provider Demographics
NPI:1831488733
Name:MACK, ERICA NIXON (PT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:NIXON
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:NIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-0897
Mailing Address - Country:US
Mailing Address - Phone:360-385-9310
Mailing Address - Fax:360-379-8826
Practice Address - Street 1:27 COLWELL ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-0897
Practice Address - Country:US
Practice Address - Phone:360-385-9310
Practice Address - Fax:360-379-8826
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00006370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist