Provider Demographics
NPI:1285600858
Name:ERICKSON, MIA L (PT, CHT)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 N 95TH LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4324
Mailing Address - Country:US
Mailing Address - Phone:623-907-0828
Mailing Address - Fax:623-907-3058
Practice Address - Street 1:3200 E CAMELBACK RD
Practice Address - Street 2:SUITE 135
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2311
Practice Address - Country:US
Practice Address - Phone:602-954-8473
Practice Address - Fax:602-954-8494
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157703000Medicaid
WVER6033581Medicare ID - Type Unspecified