Provider Demographics
NPI:1790347466
Name:DIERICKX, ERIN E
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:E
Last Name:DIERICKX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:E
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-0412
Mailing Address - Country:US
Mailing Address - Phone:206-313-3759
Mailing Address - Fax:
Practice Address - Street 1:6455 S 118TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98178-2936
Practice Address - Country:US
Practice Address - Phone:206-313-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61143094106H00000X
WAMFTA.MG.61143094106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist