Provider Demographics
NPI:1063066918
Name:PUEBLOS, ERICA MARIA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIA
Last Name:PUEBLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 PIERCY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1465
Mailing Address - Country:US
Mailing Address - Phone:310-283-9914
Mailing Address - Fax:
Practice Address - Street 1:5607 PIERCY AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1465
Practice Address - Country:US
Practice Address - Phone:310-283-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0019X
CA20020225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation