Provider Demographics
NPI:1003135484
Name:VICK-ERICKSON, LARA LEIGH (LCPC)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:LEIGH
Last Name:VICK-ERICKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 N QUEENSBURY PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0977
Mailing Address - Country:US
Mailing Address - Phone:208-761-0072
Mailing Address - Fax:
Practice Address - Street 1:1009 W HEMINGWAY BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1763
Practice Address - Country:US
Practice Address - Phone:208-453-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3737101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional