Healthcare Provider Details

I. General information

NPI: 1205972130
Provider Name (Legal Business Name): DIANE DENICE ERICKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S 6TH PL
LOWELL AR
72745-9704
US

IV. Provider business mailing address

325 S 6TH PL
LOWELL AR
72745-9704
US

V. Phone/Fax

Practice location:
  • Phone: 479-770-0700
  • Fax: 479-770-1184
Mailing address:
  • Phone: 479-770-0700
  • Fax: 479-770-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1854C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: