Healthcare Provider Details

I. General information

NPI: 1386985661
Provider Name (Legal Business Name): ERICA ROSE RUSSELL LPC-897
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16579 LOS GATOS ALMADEN ROAD
LOS GATOS CA
95032
US

IV. Provider business mailing address

16579 LOS GATOS ALMADEN ROAD
LOS GATOS CA
95032
US

V. Phone/Fax

Practice location:
  • Phone: 408-384-8404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC897
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF65551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: