Healthcare Provider Details

I. General information

NPI: 1578132569
Provider Name (Legal Business Name): TIM ERICSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 PORTLAND RD
KENNEBUNK ME
04043-6658
US

IV. Provider business mailing address

62 PORTLAND RD
KENNEBUNK ME
04043-6658
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-4211
  • Fax:
Mailing address:
  • Phone: 207-985-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TIMOTHY M. ERICSON
Title or Position: SOCIAL WORKER
Credential: MSW
Phone: 207-985-4211