Provider Demographics
NPI:1679044184
Name:ERICKSON, DEREK JOHN (LADC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JOHN
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1658
Mailing Address - Country:US
Mailing Address - Phone:507-832-8033
Mailing Address - Fax:
Practice Address - Street 1:6603 QUEEN AVE S STE N
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2000
Practice Address - Country:US
Practice Address - Phone:612-272-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305050101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)