Provider Demographics
NPI:1235104225
Name:ERICKSEN, DAVID GERALD (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GERALD
Last Name:ERICKSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 E 4500 S
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4228
Mailing Address - Country:US
Mailing Address - Phone:801-272-8957
Mailing Address - Fax:801-272-3724
Practice Address - Street 1:1414 E 4500 S
Practice Address - Street 2:SUITE 4
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4228
Practice Address - Country:US
Practice Address - Phone:801-272-8957
Practice Address - Fax:801-272-3724
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113012-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR82472Medicare UPIN