Provider Demographics
NPI:1760403323
Name:ERICKSON, SHANNON L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8022 OLD COUNTY ROAD 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6409
Mailing Address - Country:US
Mailing Address - Phone:727-641-7941
Mailing Address - Fax:727-287-9302
Practice Address - Street 1:8022 OLD COUNTY ROAD 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6409
Practice Address - Country:US
Practice Address - Phone:727-641-7941
Practice Address - Fax:727-287-9302
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW57291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761762300Medicaid