Provider Demographics
NPI:1093342412
Name:BLANK, ERIK J
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:J
Last Name:BLANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:970-613-4475
Practice Address - Street 1:4856 INNOVATION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5540
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:970-613-4475
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSWC.00000014681041C0700X
COACD.0002422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)