Provider Demographics
NPI:1669829230
Name:ERICKSON, ROGER LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LYNN
Last Name:ERICKSON
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 BROADMOOR AVE SE STE D
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-8180
Mailing Address - Country:US
Mailing Address - Phone:616-228-1914
Mailing Address - Fax:
Practice Address - Street 1:3230 BROADMOOR AVE SE STE D
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-8180
Practice Address - Country:US
Practice Address - Phone:616-228-1914
Practice Address - Fax:616-333-4927
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016004103TR0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation