Basic Information
| Provider Information | |||||||||
| NPI: | 1508581570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | GENNETTE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 TALISMAN DR UNIT C3 | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811479171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707314554 | ||||||||
| FaxNumber: | 9707311868 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 TALISMAN DR UNIT C3 | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811479171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707314554 | ||||||||
| FaxNumber: | 9707311868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HAD475 | CO | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.