Healthcare Provider Details

I. General information

NPI: 1669829230
Provider Name (Legal Business Name): ROGER LYNN ERICKSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 BROADMOOR AVE SE STE D
KENTWOOD MI
49512-8180
US

IV. Provider business mailing address

3230 BROADMOOR AVE SE STE D
KENTWOOD MI
49512-8180
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-1914
  • Fax: 616-333-4927
Mailing address:
  • Phone: 616-228-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016004
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number6301016004
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: