Provider Demographics
NPI:1215586672
Name:ERICKSON, MATTHEW P (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3662
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84323-3662
Mailing Address - Country:US
Mailing Address - Phone:435-755-8400
Mailing Address - Fax:
Practice Address - Street 1:1683 S HIGHWAY 89 # 91
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6212
Practice Address - Country:US
Practice Address - Phone:435-755-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT321034-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical