Provider Demographics
NPI:1982808077
Name:ERICKSEN, AMY MARIE (DT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:ERICKSEN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 GNARL TREE LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9678
Mailing Address - Country:US
Mailing Address - Phone:815-742-8272
Mailing Address - Fax:
Practice Address - Street 1:3718 GNARL TREE LN
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61016-9678
Practice Address - Country:US
Practice Address - Phone:815-742-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAE05370202P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist