Provider Demographics
NPI:1982669263
Name:MAXAM, ERICA (PT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MAXAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 COLLEGE ST
Mailing Address - Street 2:HSS ANCILLARY SERVICES, PC
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-1227
Mailing Address - Country:US
Mailing Address - Phone:315-824-1252
Mailing Address - Fax:315-824-8961
Practice Address - Street 1:85 COLLEGE ST
Practice Address - Street 2:HSS ANCILLARY SERVICES, PC
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-1227
Practice Address - Country:US
Practice Address - Phone:315-824-1252
Practice Address - Fax:315-824-8961
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024105225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024105OtherLICENSE
NYJ400000585Medicare PIN