Provider Demographics
NPI:1295836567
Name:ERICKSON, BRENT (MS, SAC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MS, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 HUNTERS TRL
Mailing Address - Street 2:P.O. BOX 301
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3403
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-742-4087
Practice Address - Street 1:2901 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3403
Practice Address - Country:US
Practice Address - Phone:608-742-5518
Practice Address - Fax:608-742-4087
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1521101YA0400X
WI1783-1231041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical