Basic Information
| Provider Information | |||||||||
| NPI: | 1235854779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | CHARLENE JANSSEN | ||||||||
| MiddleName: | CUARTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 DEVON ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490242601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693638002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201010798 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.