MEDICARE: SHONNA LARAINE ERICKSON MFT, LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	0650	NV

General Provider Information

NPI Number	:	1104024637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONNA LARAINE ERICKSON MFT, LADC

Provider Business Mailing Address
First Line	:	9109 DIAMOND LAKE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7064
Country	:	US
Telephone Number	:	702-804-1194
Fax Number	:	702-220-7012

Provider Business Practice Location Address
First Line	:	2780 S JONES BLVD STE I
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5625
Country	:	US
Telephone Number	:	702-220-7386
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	07/08/2007

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