Provider Demographics
NPI:1851711048
Name:ERICKSON, LISA (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CALLE BUENA
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-1800
Mailing Address - Country:US
Mailing Address - Phone:734-255-1524
Mailing Address - Fax:
Practice Address - Street 1:230 CALLE BUENA
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-1800
Practice Address - Country:US
Practice Address - Phone:734-255-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-26
Last Update Date:2014-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00012502255A2300X
IL0960032562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer