Healthcare Provider Details

I. General information

NPI: 1467810796
Provider Name (Legal Business Name): ERICA DALE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6276 W FALLSGROVE LN
PORT ORANGE FL
32128-6827
US

IV. Provider business mailing address

6276 W FALLSGROVE LN
PORT ORANGE FL
32128-6827
US

V. Phone/Fax

Practice location:
  • Phone: 504-390-9544
  • Fax:
Mailing address:
  • Phone: 504-390-9544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: