Provider Demographics
NPI:1679728356
Name:IMMKEN, ERIN KATHLEEN (LPC, LCPC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KATHLEEN
Last Name:IMMKEN
Suffix:
Gender:F
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:KATHLEEN
Other - Last Name:BOSTICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LCPC
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0098
Mailing Address - Country:US
Mailing Address - Phone:618-710-4123
Mailing Address - Fax:618-731-4082
Practice Address - Street 1:98 JUNCTION DRIVE WEST
Practice Address - Street 2:SUITE 6
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-710-4123
Practice Address - Fax:618-731-4082
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008034953101YP2500X
IL180.006806101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional