Provider Demographics
NPI:1437965936
Name:ERICKSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 FRITZ RD
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:IL
Mailing Address - Zip Code:61024-9627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6268 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4418
Practice Address - Country:US
Practice Address - Phone:815-397-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health