Healthcare Provider Details

I. General information

NPI: 1184302903
Provider Name (Legal Business Name): GREGORY ERICKSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1985 RIPKEN WAY
JACKSON MO
63755
US

IV. Provider business mailing address

1985 RIPKEN WAY
JACKSON MO
63755
US

V. Phone/Fax

Practice location:
  • Phone: 312-802-6606
  • Fax:
Mailing address:
  • Phone: 312-802-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGORY ERICKSON
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 312-802-6606