Provider Demographics
NPI:1275547440
Name:ERICSON, ROBERT CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:ERICSON
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 1:6463 4TH ST., NW
Mailing Address - Street 2:STE. C
Mailing Address - City:LOS RANCHOS DE ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107
Mailing Address - Country:US
Mailing Address - Phone:505-344-9500
Mailing Address - Fax:505-342-1084
Practice Address - Street 1:6463 4TH ST NW
Practice Address - Street 2:STE. C
Practice Address - City:LOS RANCHOS DE ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5810
Practice Address - Country:US
Practice Address - Phone:505-344-9500
Practice Address - Fax:505-342-1084
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM239103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist