Provider Demographics
NPI:1700069796
Name:ROBERT ERICSON, PHD
Entity Type:Organization
Organization Name:ROBERT ERICSON, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ERICSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-242-6672
Mailing Address - Street 1:6463 4TH ST NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOS RANCHOS DE ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5810
Mailing Address - Country:US
Mailing Address - Phone:505-344-9500
Mailing Address - Fax:505-342-1084
Practice Address - Street 1:6463 4TH ST NW
Practice Address - Street 2:SUITE C
Practice Address - City:LOS RANCHOS DE ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5810
Practice Address - Country:US
Practice Address - Phone:505-344-9500
Practice Address - Fax:505-342-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM239103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00N206OtherBLUE CROSS BLUE SHIELD
NMN8396Medicaid
NMN8396Medicaid