Provider Demographics
NPI:1265005961
Name:ERICSSON, ALEXIS ANN (RBT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ANN
Last Name:ERICSSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 S FOOTHILL DR APT 65
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2763
Mailing Address - Country:US
Mailing Address - Phone:208-540-2875
Mailing Address - Fax:
Practice Address - Street 1:525 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2995
Practice Address - Country:US
Practice Address - Phone:801-905-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-151846106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician