Healthcare Provider Details

I. General information

NPI: 1003085697
Provider Name (Legal Business Name): KRISTINE MARIA ERICKSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 BAVARIA LN BOX 71
CHASKA MN
55318-4597
US

IV. Provider business mailing address

566 BAVARIA LN BOX 71
CHASKA MN
55318-4597
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-3625
  • Fax:
Mailing address:
  • Phone: 952-448-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12353
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: