Provider Demographics
NPI:1669550604
Name:ERICKSON, TRACEY L (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:
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:PO BOX 1780
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015
Mailing Address - Country:US
Mailing Address - Phone:505-431-3822
Mailing Address - Fax:
Practice Address - Street 1:110 STATE HWY 344
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-431-3822
Practice Address - Fax:505-431-3773
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT-2023-2218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8856894Medicare PIN