Healthcare Provider Details

I. General information

NPI: 1962748616
Provider Name (Legal Business Name): ERIN MARIE WILLOUGHBY MRC, CAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063A HIGHWAY 4
JAY FL
32565-9796
US

IV. Provider business mailing address

4063A HIGHWAY 4
JAY FL
32565-9796
US

V. Phone/Fax

Practice location:
  • Phone: 937-367-6549
  • Fax:
Mailing address:
  • Phone: 937-367-6549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNONE
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: