Provider Demographics
NPI:1285291088
Name:ERICKSON, MARK WILLIAM (MS, LIMHP, LCPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MS, LIMHP, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 W 136TH PL APT 2309
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-7829
Mailing Address - Country:US
Mailing Address - Phone:608-658-4979
Mailing Address - Fax:
Practice Address - Street 1:11422 MIRACLE HILLS DR STE 401
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4420
Practice Address - Country:US
Practice Address - Phone:402-898-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5584101YM0800X
NE2662101YM0800X
KS03070101YM0800X
NE11855101YM0800X
NE2676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health