Provider Demographics
NPI:1962511691
Name:ERICKSON, ANTOINETTE L (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:'TONI'
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:193 N CEDAR BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0417
Mailing Address - Country:US
Mailing Address - Phone:303-440-4234
Mailing Address - Fax:440-442-1630
Practice Address - Street 1:350 BROADWAY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3343
Practice Address - Country:US
Practice Address - Phone:303-440-4234
Practice Address - Fax:303-442-1630
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9896351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0000089296Medicare ID - Type Unspecified