Provider Demographics
NPI:1043940547
Name:ERICKSON, CHARISSA (LICSW)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8081 PADRE WAY NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-4543
Mailing Address - Country:US
Mailing Address - Phone:612-963-0444
Mailing Address - Fax:
Practice Address - Street 1:8081 PADRE WAY NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-4543
Practice Address - Country:US
Practice Address - Phone:612-963-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical