Provider Demographics
NPI:1629186606
Name:ERICKSON, PHILIP R (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HERITAGE WAY NE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4544
Mailing Address - Country:US
Mailing Address - Phone:703-771-5100
Mailing Address - Fax:703-777-0170
Practice Address - Street 1:102 HERITAGE WAY NE
Practice Address - Street 2:SUITE 302
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5100
Practice Address - Fax:703-777-0170
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040035231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA107400OtherANTHEM
VA107399OtherANTHEM
VA295841OtherAMERIGROUP