Provider Demographics
NPI:1063971216
Name:ERICKSON, LAURIE ANN (THW & MAIS)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:THW & MAIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD. OHSU-CDRC
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-494-8060
Mailing Address - Fax:503-494-5990
Practice Address - Street 1:CDRC 901 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402
Practice Address - Country:US
Practice Address - Phone:541-744-6551
Practice Address - Fax:503-346-6918
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3697107OtherOREGON DRIVERS LICENSE