Provider Demographics
NPI:1972149094
Name:GRUSSENDORF, ERIKA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ERIKA
Middle Name:
Last Name:GRUSSENDORF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:TEXICO
Mailing Address - State:NM
Mailing Address - Zip Code:88135-0433
Mailing Address - Country:US
Mailing Address - Phone:575-519-0777
Mailing Address - Fax:
Practice Address - Street 1:101 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6306
Practice Address - Country:US
Practice Address - Phone:575-519-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-24
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-109041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical