Healthcare Provider Details

I. General information

NPI: 1568179265
Provider Name (Legal Business Name): MS. MARISSA R ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 10/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 CAMP BOWIE BLVD STE 229
FORT WORTH TX
76116-7157
US

IV. Provider business mailing address

6777 CAMP BOWIE BLVD STE 229
FORT WORTH TX
76116-7157
US

V. Phone/Fax

Practice location:
  • Phone: 682-703-1311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number88355
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: