Provider Demographics
NPI:1174068555
Name:FERNANDES, ERICA (PT, MS)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5353
Mailing Address - Country:US
Mailing Address - Phone:269-382-8489
Mailing Address - Fax:
Practice Address - Street 1:291 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5353
Practice Address - Country:US
Practice Address - Phone:269-382-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25894225100000X
MI5501017168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4374045-00Medicaid
MD1447657507OtherNPI TYPE 2/ ORGANIZATION NPI
MD1447657507OtherNPI TYPE 2/ ORGANIZATION NPI