Provider Demographics
NPI:1265054233
Name:MOLDENHAUER, ERICA ROSE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:ROSE
Last Name:MOLDENHAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 CREST DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5211
Mailing Address - Country:US
Mailing Address - Phone:760-803-8344
Mailing Address - Fax:
Practice Address - Street 1:1630 CREST DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5211
Practice Address - Country:US
Practice Address - Phone:760-803-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261OR0400X225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist