Healthcare Provider Details

I. General information

NPI: 1356296438
Provider Name (Legal Business Name): SAMANTHA ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

4434 19TH ST S
MOORHEAD MN
56560-3097
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2211
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: