Provider Demographics
NPI:1164731162
Name:ERICSON, SCOTT VANCE (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:VANCE
Last Name:ERICSON
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 8TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1354
Mailing Address - Country:US
Mailing Address - Phone:817-454-1354
Mailing Address - Fax:817-922-7895
Practice Address - Street 1:1814 8TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1354
Practice Address - Country:US
Practice Address - Phone:817-454-1354
Practice Address - Fax:817-922-7895
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9310101YM0800X
TX716106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist