Basic Information
| Provider Information | |||||||||
| NPI: | 1487873915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 809 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173731850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149001270 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.