MEDICARE: ERICA D GORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	261QD1600X	Developmental Disabilities Clinic/Center
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
5	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1629775846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA D GORE

Provider Business Mailing Address
First Line	:	1533 DUXBERRY AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-1619
Country	:	US
Telephone Number	:	614-357-1937
Fax Number	:

Provider Business Practice Location Address
First Line	:	1533 DUXBERRY AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-1619
Country	:	US
Telephone Number	:	614-357-1937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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Directions to “ ERICA D GORE ” Practice Location

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