Healthcare Provider Details

I. General information

NPI: 1053652701
Provider Name (Legal Business Name): PENELOPE JO ERICKSON MS, OTR, SWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E LOS ANGELES AVE
SIMI VALLEY CA
93065-6560
US

IV. Provider business mailing address

13561 ARROYO DALE LN
SAN DIEGO CA
92130-5789
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-7129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: