Provider Demographics
NPI:1720006943
Name:ERICSON, TIMOTHY M (LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:ERICSON
Suffix:
Gender:M
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-4033
Mailing Address - Country:US
Mailing Address - Phone:207-985-4211
Mailing Address - Fax:
Practice Address - Street 1:4 DANE ST
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7054
Practice Address - Country:US
Practice Address - Phone:207-985-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC683101YA0400X
MELC20451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME007005OtherANTHEM BLUE CROSS
MEME1807Medicare ID - Type Unspecified