Basic Information
| Provider Information | |||||||||
| NPI: | 1295836567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 HUNTERS TRL | ||||||||
| Address2: | P.O. BOX 301 | ||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425518 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425518 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1521 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 1783-123 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 1783-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.