Provider Demographics
NPI:1144740986
Name:ERICHSEN, PHILIP DAVID (MA)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:DAVID
Last Name:ERICHSEN
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 1:4150 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1208
Mailing Address - Country:US
Mailing Address - Phone:877-594-9024
Mailing Address - Fax:
Practice Address - Street 1:4150 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1208
Practice Address - Country:US
Practice Address - Phone:877-594-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health