Basic Information
| Provider Information | |||||||||
| NPI: | 1508162579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRISON | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1120 W 6TH ST | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880614104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881022 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | DEMING | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880304046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755462174 | ||||||||
| FaxNumber: | 5755444821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0131431 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 0164041 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 18677037 | 05 | NM | MEDICAID |