Provider Demographics
NPI:1639684566
Name:PANIKE, ERICK JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:JOHN
Last Name:PANIKE
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 1:1174 E GRAYSTONE WAY STE 6
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1174 E GRAYSTONE WAY STE 3
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2671
Practice Address - Country:US
Practice Address - Phone:385-200-0786
Practice Address - Fax:385-415-0567
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9334223-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14376067OtherCAQH