Provider Demographics
NPI:1245348630
Name:ERICSON, GRETCHEN LEANNE (LPC)
Entity type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:LEANNE
Last Name:ERICSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 MIRACLE LANE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-324-1255
Mailing Address - Fax:541-227-2038
Practice Address - Street 1:11 TRIPP ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7343
Practice Address - Country:US
Practice Address - Phone:541-324-1255
Practice Address - Fax:541-277-2038
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2534101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional