Provider Demographics
NPI:1861606899
Name:ERICSON, SCOTT ALLEN (PTA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALLEN
Last Name:ERICSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2059 ELVIRA WAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8082
Mailing Address - Country:US
Mailing Address - Phone:920-265-8390
Mailing Address - Fax:
Practice Address - Street 1:960 S RAPIDS RD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4146
Practice Address - Country:US
Practice Address - Phone:920-684-1144
Practice Address - Fax:920-482-0651
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI418-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant