Healthcare Provider Details

I. General information

NPI: 1548855802
Provider Name (Legal Business Name): SAMANTHA ERICSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39210 STATE ST STE 204
FREMONT CA
94538-1456
US

IV. Provider business mailing address

2143 WYANDOTTE ST APT 3
MOUNTAIN VIEW CA
94043-2368
US

V. Phone/Fax

Practice location:
  • Phone: 510-894-4135
  • Fax:
Mailing address:
  • Phone: 847-380-0387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number46-1305562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number46-1305562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: