Healthcare Provider Details

I. General information

NPI: 1861926149
Provider Name (Legal Business Name): ERICA GERALDS MDIV, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 PEACE ROSE PL
LOGANVILLE GA
30052-5112
US

IV. Provider business mailing address

4190 PEACE ROSE PL
LOGANVILLE GA
30052-5112
US

V. Phone/Fax

Practice location:
  • Phone: 678-640-3196
  • Fax:
Mailing address:
  • Phone: 678-640-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC011071
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.012703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: