Provider Demographics
NPI:1508192238
Name:ERICKSON, HEIDE
Entity Type:Individual
Prefix:
First Name:HEIDE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 S MACKINAC TRL
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9286
Mailing Address - Country:US
Mailing Address - Phone:906-632-2805
Mailing Address - Fax:906-632-1163
Practice Address - Street 1:125 N LAKE ST
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1234
Practice Address - Country:US
Practice Address - Phone:906-341-2144
Practice Address - Fax:906-341-5793
Is Sole Proprietor?:No
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802083787104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker