Provider Demographics
NPI:1861654162
Name:ERICKSON, MACKENZIE MAE (OTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MAE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72233 460TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56150-3345
Mailing Address - Country:US
Mailing Address - Phone:712-264-5693
Mailing Address - Fax:
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-264-6593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01703225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist