Provider Demographics
NPI:1902103799
Name:KNACKSTEDT, ERICK HEMANN (MA)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:HEMANN
Last Name:KNACKSTEDT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 SCARBOROUGH PASS RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8061
Mailing Address - Country:US
Mailing Address - Phone:321-276-2384
Mailing Address - Fax:
Practice Address - Street 1:668 N ORLANDO AVE STE 210
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4459
Practice Address - Country:US
Practice Address - Phone:407-215-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health