Provider Demographics
NPI:1720434558
Name:PETERSON, ERICA JAYNE (PT, DPT, ATC)
Entity type:Individual
Prefix:MS
First Name:ERICA
Middle Name:JAYNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 BOSTON ST APT 5061
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5777
Mailing Address - Country:US
Mailing Address - Phone:301-503-3897
Mailing Address - Fax:
Practice Address - Street 1:9492 DEERECO RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2102
Practice Address - Country:US
Practice Address - Phone:410-308-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225100000X
MA23713225100000X
MA29722255A2300X
MD15542255A2300X
MD29533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer