Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 6301016004 | MI |
NPI | 1669829230 |
---|---|
Provider Name | Dr. Roger Lynn Erickson |
First Address | Grand Rapids, MI 49503-5247 |
Second Address | Grand Rapids, MI 49503-5247 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2016 |
Last Update Date | 24/05/2016 |