Healthcare Provider Details

I. General information

NPI: 1710246574
Provider Name (Legal Business Name): FAMOUS ERWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 21ST ST
VERO BEACH FL
32960-0801
US

IV. Provider business mailing address

PO BOX 2622
VERO BEACH FL
32961-2622
US

V. Phone/Fax

Practice location:
  • Phone: 772-633-5350
  • Fax:
Mailing address:
  • Phone: 772-985-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC012444
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC8600
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15574
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: