Basic Information
| Provider Information | |||||||||
| NPI: | 1962675637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MOTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 803 HACIENDA LN | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874135109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752026456 | ||||||||
| FaxNumber: | 5052170429 | ||||||||
| Practice Location | |||||||||
| Address1: | 3870 FOOTHILLS RD | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880114631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755568409 | ||||||||
| FaxNumber: | 5052170429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2434 | NM | N | Other Service Providers | Specialist | 225X00000X | OT1360 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.