Healthcare Provider Details

I. General information

NPI: 1427145101
Provider Name (Legal Business Name): ERICA NICOLE THREET B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVENDELL DR
BENTON AR
72015-9188
US

IV. Provider business mailing address

2324 WALKER ST
LITTLE ROCK AR
72204-3418
US

V. Phone/Fax

Practice location:
  • Phone: 501-316-1255
  • Fax:
Mailing address:
  • Phone: 501-227-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: