Provider Demographics
NPI:1629067004
Name:ERICKSON, SUSANE (LPC)
Entity Type:Individual
Prefix:
First Name:SUSANE
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-8804
Mailing Address - Country:US
Mailing Address - Phone:304-366-7174
Mailing Address - Fax:304-225-2288
Practice Address - Street 1:448 LEONARD AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3843
Practice Address - Country:US
Practice Address - Phone:304-366-7174
Practice Address - Fax:304-366-7419
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7654101YM0800X
WV2000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ086GOtherBCBS
FL766307200Medicaid