Provider Demographics
NPI:1477046613
Name:ERICHSEN, LUKE W (PHD)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:W
Last Name:ERICHSEN
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 1:1380 PROGRESS WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6498
Mailing Address - Country:US
Mailing Address - Phone:301-829-2242
Mailing Address - Fax:301-829-2290
Practice Address - Street 1:1380 PROGRESS WAY STE 101
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6498
Practice Address - Country:US
Practice Address - Phone:301-829-2242
Practice Address - Fax:301-829-2290
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05915103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty