Provider Demographics
NPI:1902110059
Name:ERICSON, KRISTIN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:ERICSON
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 1:95 GREENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3728
Mailing Address - Country:US
Mailing Address - Phone:631-654-1967
Mailing Address - Fax:
Practice Address - Street 1:118 SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1817
Practice Address - Country:US
Practice Address - Phone:631-476-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047177-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool