Healthcare Provider Details

I. General information

NPI: 1477046613
Provider Name (Legal Business Name): LUKE W ERICHSEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 PROGRESS WAY STE 101
ELDERSBURG MD
21784-6498
US

IV. Provider business mailing address

1380 PROGRESS WAY STE 101
ELDERSBURG MD
21784-6498
US

V. Phone/Fax

Practice location:
  • Phone: 301-829-2242
  • Fax: 301-829-2290
Mailing address:
  • Phone: 301-829-2242
  • Fax: 301-829-2290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number05915
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number05915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: