Basic Information
| Provider Information | |||||||||
| NPI: | 1255537296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 W 19TH ST | ||||||||
| Address2: | STE 6 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076375808 | ||||||||
| FaxNumber: | 3074326775 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W 19TH ST | ||||||||
| Address2: | STE 6 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076375808 | ||||||||
| FaxNumber: | 3074326775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 303 | WY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 310907 | 01 | WY | BC/BS | OTHER |