Provider Demographics
NPI:1679236624
Name:KNUDSEN, ERIK
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13980 EAGLE RIDGE LAKES DR APT 201
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0702
Mailing Address - Country:US
Mailing Address - Phone:239-851-8275
Mailing Address - Fax:
Practice Address - Street 1:6290 CORPORATE CT STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3527
Practice Address - Country:US
Practice Address - Phone:239-313-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW5332101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health