Basic Information
| Provider Information | |||||||||
| NPI: | 1417111451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | DONIELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACZKO | ||||||||
| OtherFirstName: | CASSANDRA | ||||||||
| OtherMiddleName: | DONIELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 COMMERCE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685042 | ||||||||
| FaxNumber: | 6519685904 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 EAGAN WOODS DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685600 | ||||||||
| FaxNumber: | 6517303998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 07/01/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 8105 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.