Healthcare Provider Details

I. General information

NPI: 1972991628
Provider Name (Legal Business Name): IAN ERICK THOR ERICKSON LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 ALICIA RD
LAKELAND FL
33801-2104
US

IV. Provider business mailing address

930 ALICIA RD
LAKELAND FL
33801-2104
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-1950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH14501
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: