Provider Demographics
NPI:1104650464
Name:ERIKSEN, KELLY LAUREN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LAUREN
Last Name:ERIKSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LAUREN
Other - Last Name:ERIKSEN PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12 ANDREW ST APT 4
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1338
Mailing Address - Country:US
Mailing Address - Phone:786-837-4364
Mailing Address - Fax:
Practice Address - Street 1:8 N MAIN ST FL 5
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2282
Practice Address - Country:US
Practice Address - Phone:508-217-7282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health