Provider Demographics
NPI:1689778748
Name:ERICKSON, RANDI L (PSY D LP)
Entity Type:Individual
Prefix:DR
First Name:RANDI
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PSY D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 ENLOE ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8166
Mailing Address - Country:US
Mailing Address - Phone:715-377-0000
Mailing Address - Fax:715-377-0000
Practice Address - Street 1:2910 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8166
Practice Address - Country:US
Practice Address - Phone:715-377-0000
Practice Address - Fax:715-377-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2265057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39147000Medicaid