1629346853 NPI number — DR. KIRK WAYNE ERICKSON PSY.D.

Table of content: DR. KIRK WAYNE ERICKSON PSY.D. (NPI 1629346853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629346853 NPI number — DR. KIRK WAYNE ERICKSON PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
KIRK
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629346853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4160 RTE 83, SUITE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-604-0734
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 ROUTE 83
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
LONG GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-5083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-604-0734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071004736 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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