Provider Demographics
NPI:1871959791
Name:CORNELISON, ERICA (OTD, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 BEECH BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:BEECH BLUFF
Mailing Address - State:TN
Mailing Address - Zip Code:38313-9364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3118
Practice Address - Country:US
Practice Address - Phone:731-285-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005020225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist