Healthcare Provider Details

I. General information

NPI: 1124406848
Provider Name (Legal Business Name): HEATHER ERICKSON RD,LD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E MAIN ST
CROSBY MN
56441-1645
US

IV. Provider business mailing address

320 E MAIN ST
CROSBY MN
56441-1645
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number21320325
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number2330
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: