Provider Demographics
NPI:1689282204
Name:ERICKSON, ROY ETHAN (AMFT)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:ETHAN
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-7955
Mailing Address - Country:US
Mailing Address - Phone:415-409-4179
Mailing Address - Fax:415-409-1179
Practice Address - Street 1:650 EDDY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-7955
Practice Address - Country:US
Practice Address - Phone:415-409-4179
Practice Address - Fax:415-409-1179
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist