Provider Demographics
NPI:1316035231
Name:ERICKSON, CLARK J (LICSW)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:J
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 PENN AVE SO
Mailing Address - Street 2:#301, RESONNCE CENTER
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2093
Mailing Address - Country:US
Mailing Address - Phone:612-861-6129
Mailing Address - Fax:612-861-7589
Practice Address - Street 1:6701 PENN AVE SO
Practice Address - Street 2:#301, RESONNCE CENTER
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2093
Practice Address - Country:US
Practice Address - Phone:612-861-6129
Practice Address - Fax:612-861-7589
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41-1576550OtherBHP
MN901783600OtherMN CARE
MN143648OtherUCARE
MNHP37280OtherHEALTHPARTNERS
FM504S6EROtherBCBS
MN62-60891OtherUBH
MN901783600OtherMN CARE