Healthcare Provider Details

I. General information

NPI: 1417111451
Provider Name (Legal Business Name): CASSANDRA DONIELLE ERICKSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSANDRA DONIELLE MACZKO PT

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 EAGAN WOODS DR STE 120
EAGAN MN
55121-1466
US

IV. Provider business mailing address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5600
  • Fax: 651-730-3998
Mailing address:
  • Phone: 651-968-5042
  • Fax: 651-968-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8105
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: