Provider Demographics
NPI:1376631499
Name:ERICKSON, LAUREL RUZICKA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:RUZICKA
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:
Other - Last Name:RUZICKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1516 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-7218
Mailing Address - Country:US
Mailing Address - Phone:630-653-8196
Mailing Address - Fax:
Practice Address - Street 1:425 W WESLEY ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4923
Practice Address - Country:US
Practice Address - Phone:630-653-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232345OtherBLUE CROSS BLUE SHIELD