Provider Demographics
NPI:1609195114
Name:ERICKSON, AUTUMN MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:MARIE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:AUTUMN
Other - Middle Name:MARIE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1722 S LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8520
Mailing Address - Country:US
Mailing Address - Phone:805-366-4040
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-681-5190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119306106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56CCOtherASPIRA