Healthcare Provider Details

I. General information

NPI: 1164812855
Provider Name (Legal Business Name): ERICA VICTORIA JOHNSON-HERRERA OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9540 TOWNE CENTRE DR SUITE 150
SAN DIEGO CA
92121-1988
US

IV. Provider business mailing address

6424 N RIDGE BLVD APT 2H
CHICAGO IL
60626-4832
US

V. Phone/Fax

Practice location:
  • Phone: 858-952-1654
  • Fax:
Mailing address:
  • Phone: 510-277-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number056.010629
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: