Basic Information
| Provider Information | |||||||||
| NPI: | 1568179265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6777 CAMP BOWIE BLVD STE 229 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761167157 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6777 CAMP BOWIE BLVD STE 229 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761167157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6827031311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2022 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 88355 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.