Provider Demographics
NPI:1003938754
Name:SMITH, ERICKSON T (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERICKSON
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3516
Mailing Address - Country:US
Mailing Address - Phone:314-922-7139
Mailing Address - Fax:314-382-1660
Practice Address - Street 1:5920 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3516
Practice Address - Country:US
Practice Address - Phone:314-389-5737
Practice Address - Fax:314-382-1660
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0026191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493542419Medicaid