MEDICARE: DR. DAVID GERALD ERICKSEN PH.D.

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	103TC0700X	Clinical Psychologist	113012-2501	UT

General Provider Information

NPI Number	:	1235104225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID GERALD ERICKSEN PH.D.

Provider Business Mailing Address
First Line	:	1414 E 4500 S
Second Line	:	SUITE 4
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4228
Country	:	US
Telephone Number	:	801-272-8957
Fax Number	:	801-272-3724

Provider Business Practice Location Address
First Line	:	1414 E 4500 S
Second Line	:	SUITE 4
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4228
Country	:	US
Telephone Number	:	801-272-8957
Fax Number	:	801-272-3724

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	07/08/2007

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