Provider Demographics
NPI:1518378785
Name:ERICKSON, MANDY (ACMHC)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4832 W FIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8190
Mailing Address - Country:US
Mailing Address - Phone:801-678-4198
Mailing Address - Fax:
Practice Address - Street 1:5667 S REDWOOD RD UNIT 6B
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5495
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70030456009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health