Healthcare Provider Details

I. General information

NPI: 1255537296
Provider Name (Legal Business Name): CAROL JANE ERICKSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W 19TH ST STE 6
CHEYENNE WY
82001-4307
US

IV. Provider business mailing address

620 W 19TH ST STE 6
CHEYENNE WY
82001-4307
US

V. Phone/Fax

Practice location:
  • Phone: 307-637-5808
  • Fax: 307-432-6775
Mailing address:
  • Phone: 307-637-5808
  • Fax: 307-432-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number303
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: