Healthcare Provider Details

I. General information

NPI: 1629067004
Provider Name (Legal Business Name): SUSANE ERICKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 LEWIS SPEEDWAY STE 1103
SAINT AUGUSTINE FL
32084-8649
US

IV. Provider business mailing address

3910 LEWIS SPEEDWAY STE 1103
SAINT AUGUSTINE FL
32084-8649
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2273
  • Fax: 904-824-0724
Mailing address:
  • Phone: 904-829-2273
  • Fax: 904-824-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7654
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7654
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2000
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: