Basic Information
| Provider Information | |||||||||
| NPI: | 1912937749 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROL J. ERICKSON, PSYD., P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CE MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 07/04/2006 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 3076375808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 303 | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 310907 | 01 | BC/BS | OTHER |