Provider Demographics
NPI:1477924934
Name:ERICKSON, IVY (MFTI)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N NORMA ST
Mailing Address - Street 2:SUITE 127-133
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2575
Mailing Address - Country:US
Mailing Address - Phone:760-499-7406
Mailing Address - Fax:760-499-9259
Practice Address - Street 1:1400 N NORMA ST
Practice Address - Street 2:SUITE 127-133
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2575
Practice Address - Country:US
Practice Address - Phone:760-499-7406
Practice Address - Fax:760-499-9259
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94992 MFTI106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist