Healthcare Provider Details

I. General information

NPI: 1821106659
Provider Name (Legal Business Name): BRADLEY LIEF ERICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DEPARTMENT OF PSYCHIATRY
LEBANON NH
03756-1000
US

IV. Provider business mailing address

PO BOX 1918
GRANTHAM NH
03753-1918
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5508
  • Fax:
Mailing address:
  • Phone: 603-863-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberRT1492
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52282
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: