Healthcare Provider Details

I. General information

NPI: 1295040822
Provider Name (Legal Business Name): HAZEL ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 E ELENA AVE
MESA AZ
85208-5860
US

IV. Provider business mailing address

9909 E ELENA AVE
MESA AZ
85208-5860
US

V. Phone/Fax

Practice location:
  • Phone: 480-484-5077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA6716
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: