Provider Demographics
NPI:1700939386
Name:ERICKSON, MARY WANDA (OTR, L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WANDA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OTR, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13788 CROCUS ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3729
Mailing Address - Country:US
Mailing Address - Phone:763-755-5864
Mailing Address - Fax:
Practice Address - Street 1:506 ROEDER CIR
Practice Address - Street 2:88TH RRC SURGEON'S OFFICE
Practice Address - City:FORT SNELLING
Practice Address - State:MN
Practice Address - Zip Code:55111-4017
Practice Address - Country:US
Practice Address - Phone:612-713-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101266225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist