Provider Demographics
NPI:1467661694
Name:ERIKSON, RICHARD (STD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ERIKSON
Suffix:
Gender:M
Credentials:STD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2352
Mailing Address - Country:US
Mailing Address - Phone:407-629-1717
Mailing Address - Fax:407-629-7078
Practice Address - Street 1:1177 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2352
Practice Address - Country:US
Practice Address - Phone:407-629-1717
Practice Address - Fax:407-629-7078
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist