Provider Demographics
NPI:1285902304
Name:ERICKSON, AMY NICOLE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:NICOLE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:ANGULO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2765 SE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-8918
Mailing Address - Country:US
Mailing Address - Phone:772-370-9741
Mailing Address - Fax:
Practice Address - Street 1:2765 SE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-8918
Practice Address - Country:US
Practice Address - Phone:772-370-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-03
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13873235Z00000X
FLSI20342355S0801X
FLSZ6877235Z00000X
FLSA 13873235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant