Provider Demographics
NPI:1023327285
Name:ERICKSON, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 EGAN DR STE 203
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2398
Mailing Address - Country:US
Mailing Address - Phone:952-649-2005
Mailing Address - Fax:952-226-5504
Practice Address - Street 1:7447 EGAN DR STE 203
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2398
Practice Address - Country:US
Practice Address - Phone:952-649-2005
Practice Address - Fax:952-226-5504
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1225347537Medicaid