Provider Demographics
NPI:1710033543
Name:ERICSON, ROBERT HENRY JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:HENRY
Last Name:ERICSON
Suffix:JR
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 1:2642 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:S CHATHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02659
Mailing Address - Country:US
Mailing Address - Phone:508-430-8230
Mailing Address - Fax:508-430-8230
Practice Address - Street 1:2642 MAIN ST
Practice Address - Street 2:
Practice Address - City:S CHATHAM
Practice Address - State:MA
Practice Address - Zip Code:02659
Practice Address - Country:US
Practice Address - Phone:508-430-8230
Practice Address - Fax:508-430-8230
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10166871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA016687OtherTUFTS
MAP04805OtherBCBS
MA04343911901OtherHP PACIFICARE
MA254713OtherMBC HMO BLUE