Provider Demographics
NPI:1093113128
Name:ERICKSTEN, CONNIE DEAN
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:DEAN
Last Name:ERICKSTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:DEAN
Other - Last Name:EWING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:BENTLEY
Mailing Address - State:KS
Mailing Address - Zip Code:67016-0111
Mailing Address - Country:US
Mailing Address - Phone:316-796-0770
Mailing Address - Fax:
Practice Address - Street 1:111 S DEVINSHIRE AVE
Practice Address - Street 2:
Practice Address - City:BENTLEY
Practice Address - State:KS
Practice Address - Zip Code:67016-7625
Practice Address - Country:US
Practice Address - Phone:316-796-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14640101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral