1750509287 NPI number — GAIL P ERICSON, LCSW

Table of content: (NPI 1750509287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750509287 NPI number — GAIL P ERICSON, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAIL P ERICSON, LCSW
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1750509287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4119 E CATHEDRAL ROCK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85044-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-518-5550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11022 S 51ST ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-4308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-753-1211
Provider Business Practice Location Address Fax Number:
480-753-0060
Provider Enumeration Date:
04/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERICSON
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
PAULA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-753-1211

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-2009 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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